Nokea
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?
- A. Resting in the right lateral recumbent position.
- B. Using in the left lateral recumbent position.
- C. Walking around in the hallway.
- D. Sitting in a comfortable chair for a period of time.
Correct Answer: C
Rationale: In early labor (2 cm dilation), ambulation (walking) promotes labor progression by using gravity to encourage fetal descent and enhance contractions. Lateral positions are better for rest or later stages, and sitting may not aid progression as effectively.
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When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?
- A. Chorionetinitis from cytomegalovirus.
- B. Blindness secondary to gonorrhea.
- C. Cataracts from beta-hemolytic streptococcus.
- D. Strabismus resulting from neonatal maturation.
Correct Answer: B
Rationale: Erythromycin ointment is used prophylactically to prevent ophthalmia neonatorum, which can lead to blindness due to gonorrhea exposure during delivery.
A nurse is discussing sterilization with a male client. Which of the following client statements indicates understanding?
- A. A vasectomy requires a follow-up sperm count.
- B. A vasectomy prevents testosterone production.
- C. A vasectomy is effective immediately.
- D. A vasectomy is easily reversible.
Correct Answer: A
Rationale: A vasectomy requires a follow-up sperm count to confirm sterility. It does not affect testosterone production, is not effective immediately, and reversal is not always successful.
A client is considering the withdrawal method. Which of the following disadvantages should the nurse discuss?
- A. It requires medical supervision.
- B. It has a high failure rate.
- C. It protects against STIs.
- D. It is more effective than condoms.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate containing sperm and reliance on timing. It does not require medical supervision, does not protect against STIs, and is less effective than condoms.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.
When caring for a neonate born at 30 weeks' gestation who is in an isolette and receiving continuous oxygen, which of the following would the nurse use as the best method to determine the effectiveness of this treatment?
- A. Evidence of cyanosis on mouth, hands, and feet.
- B. Continuous pulse rate monitoring.
- C. Arterial blood gas levels.
- D. Percentage of oxygen delivered.
Correct Answer: C
Rationale: Arterial blood gas levels provide the most accurate assessment of oxygenation and ventilation status, indicating the effectiveness of oxygen therapy.