Nokea
A nurse is teaching a client about the use of spermicides. Which of the following client statements indicates understanding?
- A. Spermicide should be applied 10-30 minutes before intercourse.
- B. Spermicide is effective for up to 24 hours.
- C. Spermicide provides protection against STIs.
- D. Spermicide is most effective when used alone.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is effective for about 1 hour, does not protect against STIs, and is most effective with barrier methods.
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A client asks about the benefits of the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. It can reduce menstrual bleeding over time.
- B. It provides protection against HIV.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with irregular periods.
Correct Answer: A
Rationale: The hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against HIV, lasts 3-7 years, and is suitable for irregular periods.
The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?
- A. A slight drop followed by a rise in basal body temperature.
- B. A change in cervical mucus to thin, clear, and stretchy.
- C. The onset of mittelschmerz, or midcycle pelvic pain.
- D. The presence of a thick, cloudy cervical mucus.
Correct Answer: A
Rationale: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
- A. I need to increase my intake of vitamin D.
- B. I should drink at least five glasses of fluid daily.
- C. I need to get an extra 500 calories per day.
- D. I need to make sure I have enough calcium in my diet.
Correct Answer: B
Rationale: Breastfeeding mothers need 8-10 glasses of fluid daily to support milk production, so five glasses is insufficient.
The nurse discovers a medication error where a postpartum client received 400 mg of ibuprofen instead of 800 mg. The nurse should:
- A. Monitor the client for adverse effects.
- B. Administer the remaining 400 mg immediately.
- C. Notify the physician and complete an incident report.
- D. Document the dose as administered without reporting.
Correct Answer: C
Rationale: Notifying the physician and filing an incident report ensures patient safety and proper follow-up.
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.