Nokea
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
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A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F(37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order?
- A. Intravenous penicillin.
- B. Intravenous gentamicin sulfate(Garamycin).
- C. Intramuscular betamethasone(Celestone).
- D. Intramuscular cefaclor(Ceclor).
Correct Answer: A
Rationale: Penicillin is used to treat group B streptococcus.
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
- A. It's of no concern because it is such a small amount.
- B. The cause is usually related to swallowing blood during the delivery.
- C. Sometimes baby girls have this from hormones received from the mother.
- D. This vaginal spotting is caused by hemorrhagic disease of the newborn.
Correct Answer: C
Rationale: Pseudo-menstruation in female newborns is due to maternal hormone withdrawal.
A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:
- A. Move the infant away from cool window surfaces.
- B. Dry the infant quickly after delivery.
- C. Keep the infant away from air conditioning vents.
- D. Place the infant on a warmed surface.
Correct Answer: C
Rationale: Keeping the infant away from air conditioning vents prevents heat loss by convection, which occurs due to air movement.
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
- A. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy.
- B. I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Sperm can reach the ovum in 15-30 minutes under ideal conditions, which is accurate. Abstaining during the last 14 days of the cycle is not a reliable contraception method, as ovulation timing varies.
The nurse is explaining to a primagravida in labor that her baby is in a breech presentation, with the baby’s presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned?
- A. primagravida-1.png
- B. primagravida-2.png
- C. primagravida-3.png
- D. primagravida-4.png
Correct Answer: A
Rationale: This figure shows the client’s baby in a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA). Figure 3 shows a vertex presentation, left, occipit, posterior (LOP). Figure 4 shows a face position with the babyin a left, mentum, transverse position (LMT).