Nokea
Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retractions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifies the pediatrician based on the interpretation that these symptoms are associated with which of the following:
- A. Coarctation of the aorta.
- B. Atrioventricular septal defect.
- C. Pulmonary atresia.
- D. Transposition of the great arteries.
Correct Answer: A
Rationale: These symptoms are characteristic of coarctation of the aorta, which causes reduced blood flow to the lower body.
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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.
A client is considering permanent contraception. Which of the following client statements indicates a need for further teaching?
- A. Tubal ligation is considered permanent.
- B. Vasectomy requires a follow-up sperm count.
- C. Tubal ligation will cause early menopause.
- D. Both procedures require general anesthesia.
Correct Answer: C
Rationale: Tubal ligation does not cause early menopause, as it only blocks the fallopian tubes and does not affect ovarian hormone production. The other statements are correct, though anesthesia type may vary.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
A nurse is teaching a client about the use of a cervical cap. Which of the following instructions should the nurse include?
- A. Leave the cervical cap in place for at least 6 hours after intercourse.
- B. Insert the cervical cap at least 1 hour before intercourse.
- C. Reuse the cervical cap without cleaning.
- D. Apply the cervical cap to the vaginal wall.
Correct Answer: A
Rationale: The cervical cap should be left in place for at least 6 hours after intercourse to ensure effectiveness. It can be inserted up to 6 hours before intercourse, must be cleaned after use, and is applied over the cervix, not the vaginal wall.
A client asks about the side effects of the contraceptive implant. Which of the following would the nurse include?
- A. Regular menstrual cycles are guaranteed.
- B. Irregular bleeding is a common side effect.
- C. It causes significant weight loss.
- D. It increases the risk of ovarian cysts.
Correct Answer: B
Rationale: Irregular bleeding is a common side effect of the contraceptive implant, especially in the first year. It does not guarantee regular cycles, cause significant weight loss, or significantly increase ovarian cyst risk.