Nokea
A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for:
- A. Fever.
- B. Hypoglycemia.
- C. Tachycardia.
Correct Answer: C
Rationale: Tachycardia can indicate pain, stress, or cardiovascular compromise during I.V. insertion, especially in a septic preterm neonate.
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While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.
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.
A nurse is teaching a client about the use of a cervical cap. Which of the following instructions should the nurse include?
- A. Leave the cervical cap in place for at least 6 hours after intercourse.
- B. Insert the cervical cap at least 1 hour before intercourse.
- C. Reuse the cervical cap without cleaning.
- D. Apply the cervical cap to the vaginal wall.
Correct Answer: A
Rationale: The cervical cap should be left in place for at least 6 hours after intercourse to ensure effectiveness. It can be inserted up to 6 hours before intercourse, must be cleaned after use, and is applied over the cervix, not the vaginal wall.
A nurse is teaching a client about the lactational amenorrhea method. Which of the following client statements indicates a need for further teaching?
- A. I need to exclusively breastfeed for this method to work.
- B. This method is effective for up to 6 months postpartum.
- C. I can use this method even if my periods have returned.
- D. I must breastfeed on demand, including at night.
Correct Answer: C
Rationale: The lactational amenorrhea method is not effective if periods have returned, as this indicates ovulation may have resumed, requiring further teaching. The other statements are correct.
Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.