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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 potentially cause mood changes, including depression, as they can affect hormone levels. Other choices are incorrect as polyuria is excessive urination (not a common adverse effect of oral contraceptives), hypotension is low blood pressure (not typically associated with oral contraceptives), and urticaria is hives (not a common side effect of oral contraceptives).
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A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: The correct answer is A: Apply warm compresses on the breasts before feedings. Warm compresses help to promote milk flow and relieve engorgement by increasing blood flow to the area. This can make it easier for the baby to latch and feed effectively. It is important to address engorgement promptly to prevent complications such as blocked ducts or mastitis.
Option B is incorrect because allowing the infant to nurse on one breast per feeding may not fully empty the breasts, leading to further engorgement. Option C is incorrect because aspirin is not recommended during breastfeeding due to potential risks to the infant. Option D is incorrect because wearing a tight-fitting underwire bra can constrict the breasts and worsen engorgement.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (A) to monitor for preterm labor, fetal heart rate (B) to assess fetal well-being, and vaginal examination (D) to evaluate cervical changes. Gestational age (C) is typically known and doesn't require immediate reporting. Maternal blood pressure (E) is important but not a priority in this context.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.