Nokea
After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?
- A. Cardiac decompensation.
- B. Polycythemia.
- C. Splenomegaly.
- D. Reduced bilirubin levels.
Correct Answer: D
Rationale: Hemolysis due to Rh sensitization causes increased bilirubin levels, not reduced levels, indicating a need for further instruction.
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A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A primigravid client admitted to the labor area in the upper and lower lower than the lower was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is:
- A. X-linked recessive and the disease will only occur if the baby is a boy.
- B. X-linked dominant and there is no likelihood of the baby having cystic fibrosis.
- C. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.
- D. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
Correct Answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring both parents to carry the gene for the child to be affected. If the father does not carry the gene, the baby cannot have the disease but may be a carrier. X-linked and dominant inheritance patterns do not apply.
A nurse is discussing the copper IUD with a client. Which of the following client statements indicates understanding?
- A. The copper IUD is effective for up to 10 years.
- B. The copper IUD prevents ovulation.
- C. The copper IUD reduces menstrual bleeding.
- D. The copper IUD requires daily insertion.
Correct Answer: A
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It does not prevent ovulation, may increase menstrual bleeding, and does not require daily insertion.
A nurse is counseling a client about the use of barrier methods. Which of the following client statements indicates a need for further teaching?
- A. I will use a new condom for each act of intercourse.
- B. The diaphragm should be left in place for at least 6 hours after intercourse.
- C. The cervical cap can be used without spermicide.
- D. I will check the condom for tears before use.
Correct Answer: C
Rationale: The cervical cap requires spermicide for effectiveness, indicating a need for further teaching. The other statements are correct regarding condom use and diaphragm care.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.