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A nurse is teaching a client about the use of female condoms. Which of the following instructions should the nurse include?
- A. Insert the female condom up to 8 hours before intercourse.
- B. Reuse the female condom if it is undamaged.
- C. Apply spermicide to the female condom for added protection.
- D. Store female condoms in a hot environment.
Correct Answer: A
Rationale: The female condom can be inserted up to 8 hours before intercourse, providing flexibility. It cannot be reused, does not require spermicide for effectiveness, and should be stored in a cool, dry place.
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A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
- A. Uterine cramping.
- B. Abdominal distention.
- C. Hemoglobin and hematocrit.
- D. Pulse rate.
Correct Answer: D
Rationale: Pulse rate helps assess circulatory status.
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
- A. Oval.
- B. Square.
- C. Diamond shaped.
- D. Triangular.
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.
A neonate is delivered by primary cesarean section at 36 weeks' gestation. The temperature in the delivery room is 70F. To prevent heat loss from convection, which action should the nurse take?
- A. Dry the neonate quickly after delivery.
- B. Keep the neonate away from air conditioning vests.
- C. Place the neonate away from outside windows.
- D. Phewarm the bed.
Correct Answer: B
Rationale: The neonate should be kept away from drafts, such as from air conditioning vents, which may cause heat loss by convection. Convection involves heat loss due to air movement, and avoiding drafts is the most effective action.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
The nurse is performing effleurage for a primigravid client in early labor. The nurse should do which of the following?
- A. Deep kneading of superficial muscles.
- B. Secure grasping of muscular tissues.
- C. Light stroking of the skin surface.
- D. Prolonged pressure on specific sites.
Correct Answer: C
Rationale: Effleurage is a light, stroking massage of the skin surface (often the abdomen) to promote relaxation and pain relief during labor. Deep kneading, grasping, or prolonged pressure describe other massage techniques not specific to effleurage.