A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice A) is more indicative of issues like preeclampsia. Temperature elevation (choice C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice D) is more likely related to uterine contractions or gastrointestinal issues.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (Choice A). This is because an unresponsive client may be experiencing respiratory distress, which is a life-threatening situation requiring immediate intervention. Assessing respiratory function will help the nurse identify if the client is breathing adequately or if there is a need for immediate respiratory support such as airway management or assisted ventilation.
Increasing the IV fluid rate (Choice B), accessing emergency medications (Choice C), and collecting a blood sample for coagulopathy studies (Choice D) are important interventions but are not the priority in this scenario. Respiratory function takes precedence as airway and breathing are essential for life and must be addressed first to ensure the client's safety and well-being.
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.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia. Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.