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During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
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What should be included in teaching a young woman how to use the female condom?
- A. Reuse female condoms no more than five times.
- B. Refrain from using lubricant because the condom may slip out of the vagina.
- C. Wear both female and male condoms together to maximize effectiveness.
- D. Remove the condom by twisting the outer ring and pulling gently.
Correct Answer: D
Rationale: Twisting the outer ring prevents spillage of semen.
The nurse should anticipate the labor pattern for a fetal occiput posterior position to be
- A. Prolonged and more painful
- B. Precipitous
- C. Rapid during transition
- D. Shorter than average during the latent phase
Correct Answer: A
Rationale: The nurse should anticipate the labor pattern for a fetal occiput posterior position to be prolonged and more painful. This is because in occiput posterior position, the baby's head is facing the mother's abdomen instead of her back, which can lead to slower descent and dilation of the cervix. The baby's head may have difficulty rotating to the optimal position for birth, causing longer labor and increased back pain for the mother. Nurses should be prepared to provide additional support and pain management strategies for women experiencing labor with a fetal occiput posterior position.
The nurse is assessing a postpartum client who is breastfeeding. What finding requires further evaluation?
- A. Engorgement on day 3 postpartum.
- B. Mild nipple tenderness.
- C. Cracked and bleeding nipples.
- D. Colostrum present in the first 48 hours.
Correct Answer: C
Rationale: Cracked and bleeding nipples may indicate poor latch or incorrect breastfeeding technique, requiring intervention.
The nurse is working with a group of community health members to develop a plan to address the special health needs of women. Which educational program would the group most likely identify as the priority?
- A. risk reduction strategies for diabetes
- B. methods for smoking cessation
- C. ways to adopt a heart-healthy lifestyle
- D. importance of cancer screening and early detection
Correct Answer: C
Rationale: The group needs to address cardiovascular disease, the number one cause of death in women regardless of racial or ethnic group. Thus, education for adopting a heart-healthy lifestyle would be the priority.
What action is of highest priority for a nurse seeing a woman with multiple bruises accompanied by her partner?
- A. Take the woman's vital signs.
- B. Interview the woman in private.
- C. Assess for additional bruising.
- D. Document the location of the bruises.
Correct Answer: B
Rationale: Private interviews uncover hidden abuse.