Nokea
An adolescent primiparous client 24 hours postpartum asks the nurse how often she should hold her neonate. Which of the following responses would be most appropriate?
- A. Hold him when he is fussy or crying.
- B. Hold him as much as you want to hold him.
- C. Try to hold him infrequently to avoid overstimulation.
- D. You can hold him periodically throughout the day.
Correct Answer: B
Rationale: Holding the neonate as much as desired promotes bonding and emotional security without risk of overstimulation.
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A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
- A. Limiting fluid intake to 1 L daily to prevent overload.
- B. Catheterizing the bladder every 2 to 4 hours while awake.
- C. Washing the perineum with povidone iodine (Betadine) after voiding.
- D. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
Correct Answer: D
Rationale: Avoiding acidic juices reduces bladder irritation during cystitis treatment.
A client asks about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods like condoms.
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.
The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.
A nurse is counseling a client about the use of spermicides. Which of the following client statements indicates a need for further teaching?
- A. I should use spermicide with a condom for better protection.
- B. Spermicide should be applied 10-30 minutes before intercourse.
- C. Spermicide is effective for up to 24 hours after application.
- D. Spermicide may cause vaginal irritation in some users.
Correct Answer: C
Rationale: Spermicide is effective for about 1 hour after application, not 24 hours, indicating a need for further teaching. The other statements are correct.