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A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following?
- A. Estrogen
- B. Human chorionic gonadotropin (hCG)
- C. Progesterone
- D. Luteinizing hormone
Correct Answer: B
Rationale: hCG is a hormone secreted by the fertilized egg shortly after implantation. It signals the body to maintain the corpus luteum, which produces progesterone essential for sustaining the early stages of pregnancy.
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A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client who has a urinary output of 300 ml in 8 hr.
- B. A client who reports abdominal cramping during breastfeeding
- C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes
- D. A client who reports lochia rubra requiring changing perineal pads every 3 hr.
Correct Answer: C
Rationale: The nurse should notify the provider for the client who is receiving magnesium sulfate and has absent deep tendon reflexes. Absent deep tendon reflexes are a sign of magnesium toxicity, which can lead to serious complications such as respiratory depression, cardiac arrest, and death. Prompt intervention by the provider is necessary to adjust the magnesium sulfate dosage and prevent further harm to the client.
What is the primary purpose of administering vitamin K to a newborn?
- A. Prevent anemia
- B. Enhance immune function
- C. Prevent bleeding disorders
- D. Promote growth and development
Correct Answer: C
Rationale: Newborns are born with low levels of vitamin K, essential for blood clotting.
A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 2?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: B
Rationale: An MEC score of 2 indicates that there is an unacceptable health risk if the contraceptive method is used. This means that the potential health risks associated with using this particular contraceptive method outweigh the benefits. Therefore, the nurse should advise against using this method for contraception due to the elevated health risks involved. It is essential for healthcare providers to meticulously assess the medical eligibility of a patient before recommending any contraceptive method to ensure the safety and well-being of the individual.