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A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. This statement indicates an understanding of the teaching because tubal ligation does not affect ovulation; it only blocks the fallopian tubes to prevent the egg from traveling to the uterus. The client should still ovulate as before, but pregnancy is prevented by blocking the egg's path.
Incorrect choices:
A: Premenstrual tension will no longer be present - This is incorrect because tubal ligation does not affect premenstrual tension.
B: My monthly menstrual period will be shorter - This is incorrect as tubal ligation does not affect the length of menstrual periods.
C: Hormone replacements will be needed following this procedure - This is incorrect as tubal ligation does not typically require hormone replacements.
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A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best way to evaluate medication adherence for digoxin. Digoxin has a narrow therapeutic range, so monitoring the serum level ensures the client is taking the correct dose. Choices A, B, and C do not directly assess medication adherence for digoxin. Asking the client may not reflect the actual medication intake, kidney function assessment is important but not for adherence evaluation, and apical pulse rate may be affected by various factors. Checking the serum level provides objective data on the drug concentration in the body, indicating adherence.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B. Maternal cytomegalovirus can be transmitted to the newborn through saliva and urine. This is important for healthcare providers to understand as it influences infection control practices in the care of both the mother and the newborn. The other choices are incorrect because: A) Acyclovir is used to treat herpes simplex virus, not cytomegalovirus. C) Lesions are not typically visible on the mother's genitalia with cytomegalovirus. D) Airborne precautions are not required for cytomegalovirus as it is primarily transmitted through bodily fluids.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and minimal nerve endings, reducing the risk of injury and increasing absorption. This site is recommended by healthcare guidelines for administering vaccines to infants to ensure proper absorption and effectiveness. The other choices are incorrect because vigorously massaging the site (B) can cause pain and tissue damage, inserting the needle at a 45° angle (C) may not reach the muscle and can cause subcutaneous injection, and using a 21-gauge needle (D) is not specific to the site and age group, potentially causing discomfort and inadequate absorption.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemia or shock, which are serious postpartum complications. The nurse should report this to the provider immediately for further evaluation and intervention.
Other choices are not as urgent:
B: Moderate lochia serosa is expected 3 days postpartum.
C: Heart rate of 89/min is within normal range for a postpartum client.
D: BP of 120/70 mm Hg is also within normal limits.
Therefore, the nurse should prioritize reporting the cool, clammy skin over the other findings.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may indicate other neurological or developmental issues.