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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. One of its common side effects is breast tenderness due to its estrogenic effects. This occurs as a result of increased estrogen levels associated with the drug. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to medications affecting the ear, urinary frequency is not a common side effect of clomiphene citrate, and chills are not a typical adverse effect of this medication.
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A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs to rotate the pelvis, allowing the baby's shoulder to dislodge. This action enlarges the pelvic outlet, facilitating the delivery of the baby. Applying pressure to the fundus (A) or pressing on the suprapubic area (B) are not appropriate interventions for shoulder dystocia. Moving the client onto their hands and knees (C) may be helpful in some cases but is not the initial step for the McRoberts maneuver.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply post-birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating the need for prompt intervention to prevent further complications. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are small red or purple spots on the skin caused by bleeding under the skin and are not directly related to hypoglycemia. Increased muscle tone (C) is not a typical sign of hypoglycemia in newborns.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can put pressure on the baby's face, potentially leading to facial nerve injury and resulting in facial palsy. This occurs due to the compression of the facial nerve during delivery. Other choices are incorrect: A - Polycythemia is not directly related to forceps-assisted birth. B - Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C - Bronchopulmonary dysplasia is a lung condition primarily seen in premature infants requiring mechanical ventilation or oxygen therapy. In summary, facial palsy is the most likely complication following a forceps-assisted birth due to the pressure exerted on the baby's face during delivery.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (B) can lead to inaccurate results. Holding the finger above the heart prior to puncture (C) can increase blood flow and dilute the sample. In summary, selecting the lateral side of the finger for puncture is the best option to minimize pain and ensure an accurate blood glucose reading.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: Correct Answer: A) You should have your provider refit you for a new diaphragm.
Rationale: Postpartum changes in the body, such as weight fluctuations and pelvic floor tone, can affect the fit and effectiveness of a diaphragm. It is important for the client to be refitted by a healthcare provider to ensure proper sizing and optimal contraceptive efficacy.
Summary:
B) Using an oil-based vaginal lubricant can weaken the diaphragm material and increase the risk of breakage.
C) Keeping the diaphragm in place for an extended period after intercourse is not necessary and may increase the risk of toxic shock syndrome.
D) Storing the diaphragm in sterile water is not recommended as it can lead to contamination and infections.