Nokea
A nurse is teaching a client about the use of a cervical cap. Which of the following instructions should the nurse include?
- A. Leave the cervical cap in place for at least 6 hours after intercourse.
- B. Insert the cervical cap at least 1 hour before intercourse.
- C. Reuse the cervical cap without cleaning.
- D. Apply the cervical cap to the vaginal wall.
Correct Answer: A
Rationale: The cervical cap should be left in place for at least 6 hours after intercourse to ensure effectiveness. It can be inserted up to 6 hours before intercourse, must be cleaned after use, and is applied over the cervix, not the vaginal wall.
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Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
- A. Painless vaginal bleeding.
- B. Uterine tetany.
- C. Intermittent pain with spotting.
- D. Dull lower back pain.
Correct Answer: A
Rationale: Painless vaginal bleeding is characteristic of placenta previa.
The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
- A. Assessment of the fetal hematocrit level.
- B. Increase in the strength of the contractions.
- C. Increase in the fetal heart rate and variability.
- D. Assessment of fetal position.
Correct Answer: C
Rationale: Scalp stimulation is used to assess fetal well-being by eliciting a heart rate acceleration, indicating good oxygenation and variability. It does not assess hematocrit, strengthen contractions, or determine position.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retractions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifies the pediatrician based on the interpretation that these symptoms are associated with which of the following:
- A. Coarctation of the aorta.
- B. Atrioventricular septal defect.
- C. Pulmonary atresia.
- D. Transposition of the great arteries.
Correct Answer: A
Rationale: These symptoms are characteristic of coarctation of the aorta, which causes reduced blood flow to the lower body.