Nokea
The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience which of the following?
- A. No pain.
- B. Sharp pain.
- C. Light pain.
- D. Moderate pain.
Correct Answer: A
Rationale: A 'closed gate' in the gate-control theory blocks pain signals in the spinal cord, resulting in no pain or significantly reduced pain perception. Sharp, light, or moderate pain indicates an open or partially open gate.
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A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do first as soon as the neonate is delivered?
- A. Stimulate the neonate to cry vigorously.
- B. Aspirate mucus from the mouth with a bulb syringe.
- C. Begin resuscitation procedures with a bag and mask.
- D. Hold the neonate upright for the mother to view.
Correct Answer: B
Rationale: Aspirating mucus from the mouth with a bulb syringe clears the airway, which is the first priority to ensure breathing.
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
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 reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to:
- A. Assess vital signs including blood pressure every hour.
- B. Minimize environmental stimuli.
- C. Place the infant in a well-lighted area for observation.
- D. Provide stimulation to increase adaptation to the environment.
Correct Answer: B
Rationale: Minimizing environmental stimuli reduces stress and overstimulation in drug-exposed neonates, who are often hypersensitive.
A client asks about the benefits of the copper IUD. Which of the following would the nurse include?
- A. It reduces menstrual bleeding.
- B. It is hormone-free and effective for up to 10 years.
- C. It requires daily monitoring.
- D. It prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is hormone-free and effective for up to 10 years, offering long-term contraception. It may increase menstrual bleeding, does not require daily monitoring, and does not prevent ovulation.