Nokea
A nurse is teaching a client about the use of male condoms. Which of the following instructions should the nurse include?
- A. Use a water-based lubricant with latex condoms.
- B. Store condoms in a hot environment to maintain flexibility.
- C. Apply the condom after ejaculation for best results.
- D. Reuse condoms if they are undamaged.
Correct Answer: A
Rationale: Using a water-based lubricant with latex condoms prevents breakage and enhances comfort. Condoms should be stored in a cool, dry place, applied before any genital contact, and never reused.
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A client asks about the effectiveness of emergency contraception. Which of the following responses by the nurse is accurate?
- A. Emergency contraception is 100% effective if taken within 24 hours.
- B. Emergency contraception is most effective when taken within 72 hours of unprotected intercourse.
- C. Emergency contraception can be used as a regular contraceptive method.
- D. Emergency contraception requires a surgical procedure.
Correct Answer: B
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected intercourse, with efficacy decreasing over time. It is not 100% effective, not suitable for regular use, and does not require surgery.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
- A. Decreased generalized edema within 8 hours.
- B. Decreased urinary output during the first 24 hours.
- C. Sedation and decreased reflex excitability within 48 hours.
- D. Absence of any seizure activity during the first 48 hours.
Correct Answer: D
Rationale: Preventing seizures is the priority in managing severe preeclampsia.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
- A. Ask the nurses in SCN if they can take the newborn with possible sepsis now.
- B. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms.
- C. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.
- D. Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.
Correct Answer: C
Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.
The nurse is assessing a multiparous client 12 hours after vaginal delivery. Which finding requires immediate intervention?
- A. Fundus firm, 1 cm above umbilicus.
- B. Lochia rubra with small clots.
- C. Perineal pain rated 3/10.
- D. Pulse 100 bpm, temperature 100.4°F (38°C).
Correct Answer: D
Rationale: An elevated pulse and temperature may indicate infection or hemorrhage, requiring prompt intervention.