Nokea
After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?
- A. "I may develop hyperthyroidism because of my high blood pressure."
- B. "I need close monitoring because I may have a small-for-gestational-age infant."
- C. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
- D. "I may develop placenta accreta, so I need to keep my clinic appointments."
Correct Answer: B
Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.
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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 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
A client asks about the effectiveness of the contraceptive patch. Which of the following responses by the nurse is accurate?
- A. The patch is less effective than oral contraceptives.
- B. The patch is highly effective when used correctly.
- C. The patch is 100% effective in preventing pregnancy.
- D. The patch does not require a prescription.
Correct Answer: B
Rationale: The contraceptive patch is highly effective when used correctly, with a failure rate similar to oral contraceptives (about 1% with perfect use). It is not 100% effective, requires a prescription, and is not less effective than pills.
A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses?
- A. I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy.
- B. My boyfriend can buy Plan B from the pharmacy if he is over 18 years old.
- C. The birth control works by preventing ovulation or fertilization of the egg.
- D. I can be discussed and have breast tenderness or a headache after using the contraceptive.
Correct Answer: A
Rationale: Plan B is most effective when taken within 72 hours of unprotected intercourse, ideally as soon as possible. Waiting 3 to 4 days reduces its efficacy, indicating a need for further explanation.
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
- A. Red blood cell count.
- B. Degree of discomfort.
- C. Urinary output.
- D. Temperature.
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.