Nokea
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will return to the clinic in 8 weeks for my next injection
- B. I will get two shots each time I receive this medication
- C. I should increase my calcium intake while taking this medication
- D. I should discontinue this medication if I experience spotting
Correct Answer: C
Rationale: Increased calcium intake mitigates bone density loss from medroxyprogesterone, unlike incorrect 8-week injections (12 weeks), multiple shots, or stopping for spotting (normal).
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A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Offer to take the newborn to the nursery to finish his feeding
- B. Insist that the mother pick up the newborn to feed him
- C. Demonstrate how to hold the newborn and allow the client to practice
- D. Persuade the client to breastfeed the newborn to promote bonding
Correct Answer: C
Rationale: Demonstrating safe holding respects the client's concerns while promoting bonding, unlike nursery removal, insistence, or pushing breastfeeding.
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
- A. Eversion of the great toe
- B. Flexion of the forearm
- C. The downward curl of the toes
- D. Extension of the leg
Correct Answer: A
Rationale: A positive Babinski reflex in newborns shows dorsiflexion and fanning of toes, unlike forearm flexion, toe curling, or leg extension.
A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?
- A. Dizziness
- B. Increased urination
- C. Double vision
- D. Sweating
Correct Answer: B
Rationale: Increased urination (polyuria) is a hallmark of hyperglycemia as the body excretes excess glucose, unlike dizziness, double vision, or sweating (more hypoglycemic symptoms).
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations is an adverse reaction to the medication?
- A. Hypertension
- B. Hypoglycemia
- C. Respiratory rate 16/min
- D. Urine output 20 mL/hr
Correct Answer: D
Rationale: Urine output of 20 mL/hr suggests oliguria, risking magnesium toxicity due to poor renal excretion, unlike hypertension (preeclampsia symptom), hypoglycemia (unrelated), or normal respiratory rate.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Abdominal distention
- B. Third-degree perineal laceration
- C. Vaginal candidiasis
- D. Afterpain
Correct Answer: B
Rationale: A third-degree perineal laceration contraindicates suppositories to avoid further trauma and delayed healing, unlike distention, candidiasis, or afterpain, which are not contraindications.