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On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the physician immediately because of the possibility of:
- A. Ectopic pregnancy.
- B. Abruptio placentae.
- C. Gestational trophoblastic disease.
- D. Complete abortion.
Correct Answer: A
Rationale: Severe pain and hypotension suggest ectopic pregnancy.
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A nurse is discussing sterilization options with a male client. Which of the following statements by the client indicates a need for further teaching?
- A. A vasectomy involves cutting the vas deferens to prevent sperm release.
- B. I will need to use another contraceptive method until my sperm count is zero.
- C. A vasectomy will decrease my testosterone levels.
- D. A vasectomy is considered a permanent form of contraception.
Correct Answer: C
Rationale: A vasectomy does not decrease testosterone levels, as the testes continue to produce hormones. The other statements are correct, indicating a need for further teaching about hormonal effects.
When assessing a 16-year-old primigravid client at 37 weeks' gestation diagnosed with severe preeclampsia, which of the following indicates the client needs continued management for the preeclampsia?
- A. Blood pressure of 138/94 mm Hg.
- B. Severe blurring of vision.
- C. Less than 2 g of protein in a 24-hour sample.
- D. Weight gain of 0.5 lb in 1 week.
Correct Answer: B
Rationale: Severe blurring of vision indicates worsening preeclampsia.
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
- A. Football hold.
- B. Scissors hold.
- C. Cross-cradle hold.
- D. Cradle hold.
Correct Answer: A
Rationale: The football hold minimizes pressure on the cesarean incision, promoting comfort during breastfeeding.
A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
- A. I will wear a sports bra or a well fitting bra for several days.
- B. When showering, I'll direct water onto my shoulders.
- C. I will only use only water to clean my nipples.
- D. I will use a breast pump to remove any milk that may appear.
Correct Answer: D
Rationale: Using a breast pump can stimulate milk production, which is counterproductive for bottle-feeding mothers.
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in the neonate?
- A. Anemia.
- B. Hypoglycemia.
- C. Delayed meconium.
- D. Elevated bilirubin.
Correct Answer: B
Rationale: Large-for-gestational-age neonates (e.g., 4,082 g) are at risk for hypoglycemia due to increased metabolic demand and potential maternal diabetes. Hypoglycemia screening is a priority. Anemia, delayed meconium, or hyperbilirubinemia are less immediate.