Nokea
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
- A. I should perform breast self-examination on the day my menstrual flow begins.
- B. It's important that I perform breast self-examination on the same day each month.
- C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.
- D. If there is discharge from my nipples, I should call my health care provider.
Correct Answer: D
Rationale: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.
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The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with pregnancy-induced hypertension to the labor and delivery area. Which of the following client care rooms is most appropriate for this client?
- A. A brightly lit private room at the end of the hall.
- B. A semiprivate room midway down the hall from the nurses' station.
- C. A private room with many windows that is near the operating room.
- D. A darkened private room as close to the nurses' station as possible.
Correct Answer: D
Rationale: Pregnancy-induced hypertension requires close monitoring for seizures (eclampsia). A darkened private room near the nurses' station minimizes stimulation and ensures rapid access to care.
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
- A. I need to increase my intake of vitamin D.
- B. I should drink at least five glasses of fluid daily.
- C. I need to get an extra 500 calories per day.
- D. I need to make sure I have enough calcium in my diet.
Correct Answer: B
Rationale: Breastfeeding mothers need 8-10 glasses of fluid daily to support milk production, so five glasses is insufficient.
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following?
- A. Nubain (nalbuphine) and Phenergan (promethazine) will give relief from pain and nausea during early labor.'
- B. I can have an epidural as soon as I start contracting.'
- C. If I have a cesarean, I can have an epidural.'
- D. If I have an emergency cesarean, I may be put to sleep for the delivery.'
Correct Answer: B
Rationale: Epidurals are typically administered in active labor (e.g., 4–5 cm dilation), not immediately upon contracting, indicating a need for further teaching. The other statements are accurate regarding pain relief options.
A client asks about the disadvantages of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. It requires daily insertion.
- B. It may cause nausea or breast tenderness.
- C. It is less effective than condoms.
- D. It causes permanent infertility.
Correct Answer: B
Rationale: The vaginal contraceptive ring may cause nausea or breast tenderness, especially initially. It is inserted once every 3 weeks, is more effective than condoms when used correctly, and does not cause permanent infertility.
While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.