Nokea
A nurse is teaching a client about the use of the contraceptive injection. Which of the following client statements indicates a need for further teaching?
- A. I will need an injection every 3 months.
- B. The injection may cause irregular bleeding.
- C. The injection is reversible, but fertility may take time to return.
- D. The injection will protect me from STIs.
Correct Answer: D
Rationale: The contraceptive injection does not protect against STIs, indicating a need for further teaching. The other statements are correct regarding frequency, side effects, and reversibility.
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A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following?
- A. More than $50 \%$ of neonates born to mothers who are positive for HIV will be positive at 18 months of age.'
- B. An enlarged liver at birth generally means the neonate is HIV positive.'
- C. A complete blood count analysis is the primary method for determining whether the neonate is HIV positive.'
- D. Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time.'
Correct Answer: D
Rationale: Most neonates born to HIV-positive mothers test positive for HIV antibodies at birth due to maternal antibody transfer but are asymptomatic, with true infection status determined later.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
- A. Six to eight wet diapers by the fifth day.
- B. Three to four transitional stools on the fourth day.
- C. Ability to fall asleep easily after feeding on the first day.
- D. Regain of lost birth weight by the third day.
Correct Answer: A
Rationale: Six to eight wet diapers by the fifth day indicate adequate milk intake.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
A nurse is discussing the withdrawal method with a client. Which of the following client statements indicates a need for further teaching?
- A. I understand it has a high failure rate.
- B. My partner needs to withdraw before ejaculation.
- C. It provides some protection against STIs.
- D. It requires careful timing and control.
Correct Answer: C
Rationale: The withdrawal method does not provide protection against STIs, indicating a need for further teaching. The other statements are correct regarding its high failure rate, need for withdrawal before ejaculation, and requirement for timing and control.