Nokea
A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
- A. "RhoGAM will protect my next baby if it is Rh-negative."
- B. "RhoGAM will prevent antibody formation in my blood."
- C. "RhoGAM will be given to prevent German measles."
- D. "RhoGAM will be used to prevent bleeding in my newborn."
Correct Answer: B
Rationale: RhoGAM prevents maternal antibody formation against Rh-positive blood.
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A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
The nurse is managing care of a primigravida at full term who is in active labor. What should be included in developing the plan of care for this client?
- A. Oxygen saturation monitoring every half hour.
- B. Supine positioning on back, if it is comfortable.
- C. Anesthesia/pain level assessment every 30 minutes.
- D. Vaginal bleeding, ROM assessment every shift.
Correct Answer: C
Rationale: Regular assessment of anesthesia/pain levels is critical to ensure the client's comfort and to adjust pain management strategies as labor progresses. Oxygen saturation monitoring is not typically required every half hour unless specific complications arise. Supine positioning can cause supine hypotensive syndrome and is generally avoided. Vaginal bleeding and rupture of membranes (ROM) assessments are important but typically performed more frequently than every shift during active labor.
A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
- A. Fat.
- B. Iron.
- C. Sodium.
- D. Calcium.
Correct Answer: A
Rationale: Breast milk has higher fat content, which is essential for neonatal growth and brain development.
A nurse is teaching a client about the fertility awareness method. Which of the following instructions should the nurse include?
- A. Track basal body temperature and cervical mucus daily.
- B. Avoid intercourse throughout the entire menstrual cycle.
- C. Use this method if you have irregular periods.
- D. Monitor ovulation with a home pregnancy test.
Correct Answer: A
Rationale: Tracking basal body temperature and cervical mucus daily is essential for the fertility awareness method to identify fertile days. Intercourse is avoided only during fertile periods, the method is less reliable with irregular periods, and pregnancy tests do not monitor ovulation.
A client is considering the cervical cap. Which of the following client statements indicates understanding?
- A. I need a prescription for the cervical cap.
- B. The cervical cap can be left in place for up to 72 hours.
- C. The cervical cap does not require spermicide.
- D. The cervical cap is more effective after childbirth.
Correct Answer: A
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider. It can be left in place for up to 48 hours, requires spermicide, and is less effective after childbirth.