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A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to:
- A. Assess vital signs including blood pressure every hour.
- B. Minimize environmental stimuli.
- C. Place the infant in a well-lighted area for observation.
- D. Provide stimulation to increase adaptation to the environment.
Correct Answer: B
Rationale: Minimizing environmental stimuli reduces stress and overstimulation in drug-exposed neonates, who are often hypersensitive.
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A nurse is counseling a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Apply spermicide 10-30 minutes before intercourse.
- B. Use spermicide alone for maximum effectiveness.
- C. Leave spermicide in place for at least 24 hours.
- D. Apply spermicide after intercourse.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is not most effective alone, should not be left for 24 hours, and is applied before, not after, intercourse.
When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?
- A. Return visit to the prenatal clinic in approximately 4 weeks.
- B. Decreased edema after 1 week of a low-protein, low-fiber diet.
- C. Bed rest on the left side during the day, with bathroom privileges.
- D. Immediate reporting of adverse reactions to magnesium sulfate therapy.
Correct Answer: C
Rationale: Bed rest on the left side enhances placental perfusion and reduces blood pressure.
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
- A. Taking in.
- B. Taking on.
- C. Taking hold.
- D. Letting go.
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.
A client is considering the withdrawal method. Which of the following disadvantages should the nurse discuss?
- A. It requires medical supervision.
- B. It has a high failure rate.
- C. It protects against STIs.
- D. It is more effective than condoms.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate containing sperm and reliance on timing. It does not require medical supervision, does not protect against STIs, and is less effective than condoms.
A newly delivered primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation?
- A. Neonates primarily focus on moving objects.
- B. They can see objects up to 12 inches away.
- C. Usually they see clearly by about 2 days after birth.
- D. Neonates primarily distinguish light from dark.
Correct Answer: B
Rationale: Neonates can focus on objects about 8-12 inches away, which is optimal for bonding during feeding.