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A primiparous client, 24 hours post-cesarean, reports incisional pain rated 6/10. The nurse should first:
- A. Administer prescribed analgesics.
- B. Encourage deep breathing exercises.
- C. Apply a warm compress to the incision.
- D. Assess the incision for signs of infection.
Correct Answer: A
Rationale: Administering analgesics addresses pain promptly, promoting comfort and mobility.
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A client asks about the benefits of the copper IUD. Which of the following would the nurse include?
- A. It reduces menstrual bleeding.
- B. It is hormone-free and effective for up to 10 years.
- C. It requires daily monitoring.
- D. It prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is hormone-free and effective for up to 10 years, offering long-term contraception. It may increase menstrual bleeding, does not require daily monitoring, and does not prevent ovulation.
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to:
- A. Tightly swaddle the neonate.
- B. Feed the neonate extra, high-calorie formula.
- C. Keep the neonate in a brightly lit environment.
- D. Touch the baby only when he is crying.
Correct Answer: A
Rationale: Tightly swaddling the neonate provides comfort and reduces overstimulation in cocaine-exposed neonates.
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/hour I.V. piggyback. The pharmacy sends the I.V. to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
Correct Answer: 50
Rationale: To calculate the correct dose: (2 g/hour * 500 mL) / 20 g = 50 mL/hour.
A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
- A. The medication will be administered while I am in a side-lying position.'
- B. The anesthetic may cause a severe headache which is treatable.'
- C. My blood pressure may increase if I lie down too soon after the injection.'
- D. I can expect immediate anesthesia that can be reversed very easily.'
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.