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A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression
- B. Polyuria
- C. Hypotension
- D. Urticaria
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can cause mood changes, including depression, as an adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor the client's mental health. Polyuria (B) is excessive urination, not associated with oral contraceptives. Hypotension (C) is low blood pressure, not a common adverse effect of oral contraceptives. Urticaria (D) is hives, typically not linked to this medication.
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Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen to help dislodge the impacted shoulder. This action widens the pelvic outlet, allowing for easier delivery of the baby. Applying pressure to the fundus (A) does not address the shoulder dystocia. Pressing firmly on the suprapubic area (B) may not be effective in resolving the shoulder dystocia. Moving the client onto their hands and knees (C) may not provide the optimal position for resolving the shoulder dystocia. Therefore, assisting the client in pulling their knees toward their abdomen (D) is the most appropriate action to help alleviate the shoulder dystocia and facilitate the delivery of the baby.
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 withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. 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 be seen in other conditions, but not specifically in newborns with this syndrome.
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: Transmission can occur via the saliva and urine of the newborn. This is because cytomegalovirus (CMV) is commonly spread through bodily fluids like saliva, urine, and breast milk. It is important for the nurse manager to emphasize this point to the newly licensed nurses to highlight the potential routes of transmission.
Choice A is incorrect because acyclovir is not used for the treatment of CMV; it is used for herpes simplex virus infections. Choice C is incorrect because CMV typically does not present with visible lesions on the mother's genitalia. Choice D is incorrect because CMV is not transmitted through airborne routes, so airborne precautions are not necessary. It is important to focus on educating about the correct modes of transmission to prevent the spread of CMV.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (A) does not address the immediate issue of bladder distention. Administering simethicone (B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (D) may be uncomfortable and does not address the underlying bladder distention.