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A nurse is leading a discussion about contraception with a group of 14-year-old-client. After the presentation a client asks the client which method would be best for her to use. How should the nurse respond?
- A. "Because of your age, i think that a barrier method would be the best choice."
- B. "Before i can help you, i need to know more about your sexual activity."
- C. "A provider can help you with that after a physical examination."
- D. "You are so young. Are you ready for the responsibilities of a sexual relationship?"
Correct Answer: B
Rationale: The appropriate response for the nurse to provide to the 14-year-old client who asks the best contraception method for her is to gather more information about her sexual activity first. This approach is essential in understanding the client's individual needs and situation before recommending a suitable contraceptive method. It allows the nurse to offer personalized and accurate advice based on the client's specific circumstances, rather than making assumptions or providing generic recommendations. By starting with a discussion about the client's sexual activity, the nurse can ensure that the advice given is tailored to the client's needs and preferences, promoting informed decision-making and effective contraceptive use.
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After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
The nurse is describing different types of abruptio placenta to a group of students explaining that the incomplete abruptio placenta is
- A. There is massive bleeding in the presence of almost total separation
- B. Separation beginning at the periphery of the placenta
- C. The placenta separates centrally and there can be concealed bleeding
- D. Blood passes between the fetal membrane of the uterine wall and is skipped vaginally
Correct Answer: B
Rationale: In incomplete abruptio placenta, the separation begins at the periphery of the placenta. This results in partial detachment of the placenta from the uterine wall, rather than almost total separation as seen in complete abruptio placenta. This type of abruptio placenta may present with vaginal bleeding depending on the extent of separation and may lead to various degrees of maternal and fetal compromise.
A 30-year-old woman is considering the use of emergency contraception. Which of the following is true about its use?
- A. It is most effective when used within 72 hours after unprotected sex.
- B. It should be used at least 5 days after unprotected sex to be effective.
- C. It prevents implantation of a fertilized egg into the uterine wall.
- D. It requires a prescription from a healthcare provider.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?
- A. "Your stomach will empty rapidly"
- B. "You should expect your uterus to double in size"
- C. "You should anticipate nasal stuffiness."
- D. "Your nipples will become lighter in color".
Correct Answer: B
Rationale: Option B, "You should expect your uterus to double in size," is the correct information to include when discussing expected changes during pregnancy at 24 weeks of gestation. By this time, the uterus has significantly expanded to accommodate the growing fetus, which is the most notable physical change during pregnancy. It is essential for the client to understand the normal physiological changes that occur during pregnancy to ensure they are informed and prepared for the expected progression of their pregnancy.
A patient at 24 weeks of gestation reports that she has a glass of wine with dinner every evening. Which rationale should the nurse provide this patient regarding the necessity to eliminate alcohol intake? N R I G B.C M U S N T O
- A. The fetus is placed at risk for altered brain growth.
- B. The fetus is at risk for severe nervous system injury.
- C. The patient will be at risk for abusing other substances as well.
- D. A daily consumption of alcohol indicates a risk for alcoholism.
Correct Answer: A
Rationale: The correct rationale that the nurse should provide to the patient regarding the necessity to eliminate alcohol intake during pregnancy is that the fetus is placed at risk for altered brain growth. Alcohol consumption during pregnancy can lead to a condition known as Fetal Alcohol Syndrome (FAS), which is characterized by various physical and intellectual disabilities in the child. One of the major consequences of alcohol exposure during pregnancy is impaired brain development in the fetus. This can result in cognitive, behavioral, and neurological problems that may persist throughout the child's life. Therefore, it is crucial for pregnant women to completely abstain from alcohol to protect the health and well-being of the developing fetus.