Nokea
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.
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After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
A nurse is teaching a client about the use of male condoms. Which of the following instructions should the nurse include?
- A. Use a water-based lubricant with latex condoms.
- B. Store condoms in a hot environment to maintain flexibility.
- C. Apply the condom after ejaculation for best results.
- D. Reuse condoms if they are undamaged.
Correct Answer: A
Rationale: Using a water-based lubricant with latex condoms prevents breakage and enhances comfort. Condoms should be stored in a cool, dry place, applied before any genital contact, and never reused.
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
- A. Check the status of the fetal heart rate.
- B. Turn the client to her right side.
- C. Test the leaking fluid with nitrazine paper.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.
A neonate with heart failure is being discharged home. In teaching the parents about the neonate's nutritional needs, the nurse should explain that:
- A. Fluids should be restricted.
- B. Decreased activity level should reduce the need to additional reduces.
- C. The formula should be low in sodium.
- D. The neonate may need a formula with higher calories per fluid ounce.
Correct Answer: D
Rationale: A neonate with heart failure may require a higher-calorie formula to meet energy needs without increasing fluid volume.
A nurse is discussing the copper IUD with a client. Which of the following client statements indicates understanding?
- A. The copper IUD is effective for up to 10 years.
- B. The copper IUD prevents ovulation.
- C. The copper IUD reduces menstrual bleeding.
- D. The copper IUD requires daily insertion.
Correct Answer: A
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It does not prevent ovulation, may increase menstrual bleeding, and does not require daily insertion.