Nokea
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next:
- A. Apply an ice pack to the perineal area.
- B. Assess the client's temperature.
- C. Have the client take a warm sitz bath.
- D. Contact the physician for orders for an antibiotic.
Correct Answer: A
Rationale: Applying an ice pack reduces swelling and bruising in the perineal area, which is appropriate for the described symptoms.
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A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.
The physician determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean delivery with general anesthesia. Before the cesarean delivery, the anesthesiologist orders cimetidine (Tagamet) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following?
- A. Incidence of bronchospasm.
- B. Oral and respiratory secretions.
- C. Acid level of the stomach contents.
- D. Incidence of postoperative gastric ulcer.
Correct Answer: C
Rationale: Cimetidine, an H2-receptor blocker, is given before general anesthesia to reduce gastric acid levels, minimizing the risk of aspiration pneumonitis. It does not affect bronchospasm, secretions, or postoperative ulcers directly.
A client asks about the effectiveness of the vaginal contraceptive ring. Which of the following responses by the nurse is accurate?
- A. The ring is 100% effective in preventing pregnancy.
- B. The ring is highly effective when used correctly.
- C. The ring does not require a prescription.
- D. The ring is less effective than condoms.
Correct Answer: B
Rationale: The vaginal contraceptive ring is highly effective when used correctly, with a low failure rate. It is not 100% effective, requires a prescription, and is generally more effective than condoms.
A client at 28 weeks' gestation in premature labor was placed on ritodrine(Yutopar). To maintain the pregnancy, the physician orders the client to have 10 mg now, 10 mg in 2 hours, and then 20 mg every 4 hours while contractions persist, not to exceed the maximum daily oral dose of 120 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 10:00 a.m. and follows the physician's order?
- A. 10:00 a.m.
- B. 10:00 p.m.
- C. 12:00 a.m.
- D. 2:00 a.m.
Correct Answer: B
Rationale: The client will reach the maximum dose at 10:00 p.m.
A client asks about the risks of the contraceptive patch. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Permanent infertility.
- C. Guaranteed weight loss.
- D. Elimination of menstrual periods.
Correct Answer: A
Rationale: The contraceptive patch may increase the risk of blood clots, especially in smokers or those with risk factors. It does not cause permanent infertility, guarantee weight loss, or eliminate periods (it causes withdrawal bleeding).