Nokea
The nurse is preparing a 51-year-old client for a vaginal examination. The nurse should place the client in which position?
- A. Prone
- B. Lateral Sims’
- C. Lithotomy
- D. High Fowler’s
Correct Answer: C
Rationale: The correct answer is C: Lithotomy position. This position allows for optimal visualization of the vaginal area and easier access for the examination. The client lies on their back with knees flexed and feet in stirrups, providing proper exposure. Prone (A) is face down and not suitable for a vaginal exam. Lateral Sims' (B) is on the side and not ideal for this exam. High Fowler's (D) is sitting upright, which is not appropriate for a vaginal examination.
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A client with a history of herpes simplex virus (HSV-2) infection asks the nurse about future sexual activity. Which response is most appropriate?
- A. If the infection has healed, you do not have to use a condom.
- B. Refrain from all sexual activity.
- C. Use a condom during sexual activity only if the infection becomes active again.
- D. Inform all potential sexual partners about the infection, even if it is inactive.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Informing all potential sexual partners about the HSV-2 infection, even if inactive, is crucial to ensure transparency and promote informed decision-making.
2. HSV-2 can be transmitted even when symptoms are not present, so partners need to be aware of the risk.
3. This approach demonstrates respect for the partners' autonomy and enables them to make choices regarding their own health.
Summary:
A: Incorrect. Using a condom is important even when the infection is inactive to prevent transmission.
B: Incorrect. Refraining from all sexual activity may not be necessary if proper precautions are taken.
C: Incorrect. Using a condom only when the infection is active does not fully address the risk of transmission during asymptomatic periods.
The nurse is teaching a woman receiving adjuvant hormonal therapy on how she can manage her side effects and symptoms. Which education and teaching will the nurse include? Select all that apply.
- A. Wear layered clothing and avoid caffeine and spicy foods to help relieve hot flashes
- B. Decrease vaginal dryness by using vaginal moisturizers such as Replens or vitamin E suppositories daily
- C. Manage nausea and vomiting by consuming a bland diet and taking medication first thing in the morning.
- D. Ease musculoskeletal symptoms with warm baths and nonsteroidal analgesics
Correct Answer: B
Rationale: The correct answer is B. Vaginal dryness is a common side effect of hormonal therapy. Using vaginal moisturizers like Replens or vitamin E suppositories can help alleviate this symptom by providing moisture and lubrication. This intervention can improve the woman's comfort and quality of life during treatment.
Choice A is incorrect because wearing layered clothing and avoiding caffeine and spicy foods are strategies typically recommended for managing hot flashes, not vaginal dryness.
Choice C is incorrect as managing nausea and vomiting with a bland diet and medication is not directly related to the management of side effects of hormonal therapy like vaginal dryness.
Choice D is incorrect as warm baths and nonsteroidal analgesics are more commonly used to ease musculoskeletal symptoms, not specifically for managing vaginal dryness.
Most congenital anomalies of the central nervous system (CNS) result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process?
- A. Maternal diabetes
- B. Maternal folic acid deficiency
- C. Socioeconomic status
- D. Maternal use of anticonvulsant
Correct Answer: B
Rationale: The correct answer is B: Maternal folic acid deficiency. Folic acid is essential for neural tube closure. Deficiency can lead to neural tube defects in the fetus. Maternal diabetes (choice A) can increase the risk, but it's not the primary factor. Socioeconomic status (choice C) may indirectly impact nutrition but isn't directly related to neural tube closure. Maternal use of anticonvulsants (choice D) can increase the risk, but it's not as significant as folic acid deficiency in neural tube closure.
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal?
- A. +1.'
- B. +2.'
- C. +3.'
- D. +4.'
Correct Answer: C
Rationale: The correct answer is C: +3'. This indicates brisk reflexes. A: +1' indicates a low-normal response, B: +2' indicates a normal response, and D: +4' indicates hyperactive reflexes. +3' is slightly brisker than normal, reflecting an increased response without being hyperactive.
Intrapartum nursing care for a woman who has sickle cell disease focuses on:
- A. Maintaining oxygenation and preventing dehydration
- B. Controlling pain and avoiding unnecessary movement
- C. Preventing excess exertion and limiting visitors
- D. Increasing calorie intake and avoiding internal monitoring
Correct Answer: A
Rationale: The correct answer is A because maintaining oxygenation is crucial due to the risk of vaso-occlusive crisis in sickle cell disease. Dehydration can worsen sickling of red blood cells. Choice B is incorrect because pain control is important but not the primary focus. Choice C is incorrect as excess exertion can trigger a crisis, and limiting visitors is not a priority. Choice D is incorrect as calorie intake and internal monitoring are not directly related to intrapartum care for sickle cell disease.