Nokea
The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with pregnancy-induced hypertension to the labor and delivery area. Which of the following client care rooms is most appropriate for this client?
- A. A brightly lit private room at the end of the hall.
- B. A semiprivate room midway down the hall from the nurses' station.
- C. A private room with many windows that is near the operating room.
- D. A darkened private room as close to the nurses' station as possible.
Correct Answer: D
Rationale: Pregnancy-induced hypertension requires close monitoring for seizures (eclampsia). A darkened private room near the nurses' station minimizes stimulation and ensures rapid access to care.
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After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
- A. I should perform breast self-examination on the day my menstrual flow begins.
- B. It's important that I perform breast self-examination on the same day each month.
- C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.
- D. If there is discharge from my nipples, I should call my health care provider.
Correct Answer: D
Rationale: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.
A client asks about the benefits of the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. It can reduce menstrual bleeding over time.
- B. It provides protection against HIV.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with irregular periods.
Correct Answer: A
Rationale: The hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against HIV, lasts 3-7 years, and is suitable for irregular periods.
A nurse is discussing the contraceptive sponge with a client. Which of the following client statements indicates understanding?
- A. I need to insert the sponge at least 1 hour before intercourse.
- B. The sponge can be left in place for up to 24 hours.
- C. The sponge is more effective after childbirth.
- D. The sponge protects against HIV.
Correct Answer: B
Rationale: The contraceptive sponge can be left in place for up to 24 hours, providing flexibility. It should be inserted just before intercourse (not 1 hour prior), is less effective after childbirth, and does not protect against HIV.
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
A client asks about the side effects of the contraceptive implant. Which of the following would the nurse include?
- A. Regular menstrual cycles are guaranteed.
- B. Irregular bleeding is a common side effect.
- C. It causes significant weight loss.
- D. It increases the risk of ovarian cysts.
Correct Answer: B
Rationale: Irregular bleeding is a common side effect of the contraceptive implant, especially in the first year. It does not guarantee regular cycles, cause significant weight loss, or significantly increase ovarian cyst risk.