Nokea
The nurse provides education to the person undergoing a surgical abortion. What response by the person shows an understanding of the education?
- A. “It’s good I won’t have any pain after the procedure.â€
- B. “I think I’m sure about my decision.â€
- C. “I should call if I soak a pad in 2 hours.â€
- D. “I should follow up for contraception counseling at my annual exam in 6 months.â€
Correct Answer: C
Rationale: The correct answer is C because soaking a pad in 2 hours could indicate excessive bleeding, a potential complication after a surgical abortion. This response shows understanding of the education provided by the nurse about when to seek immediate medical attention.
Choice A is incorrect because it is not true that there will be no pain after a surgical abortion; pain is a common experience post-procedure. Choice B is incorrect because it does not demonstrate an understanding of the key information provided during education. Choice D is incorrect because contraception counseling should be addressed sooner than 6 months post-abortion to prevent unintended pregnancies.
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A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
The nurse is caring for a client in labor with ruptured membranes. What finding suggests umbilical cord prolapse?
- A. Clear amniotic fluid.
- B. Variable decelerations on the fetal monitor.
- C. Contractions every 2 minutes.
- D. Maternal blood pressure of 110/70 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Variable decelerations on the fetal monitor. This finding suggests umbilical cord prolapse because the cord can become compressed during contractions, leading to variable decelerations. It is a serious complication that requires immediate intervention to prevent fetal distress.
A: Clear amniotic fluid is a normal finding after rupture of membranes.
C: Contractions every 2 minutes may indicate tachysystole, but not specifically cord prolapse.
D: Maternal blood pressure is not directly related to cord prolapse.
The nurse is caring for a client in the third trimester reporting severe right upper quadrant pain and nausea. What condition should the nurse suspect?
- A. Placenta previa.
- B. HELLP syndrome.
- C. Hyperemesis gravidarum.
- D. Abruptio placentae.
Correct Answer: B
Rationale: The correct answer is B: HELLP syndrome. In the third trimester, severe right upper quadrant pain and nausea can indicate HELLP syndrome, a serious pregnancy complication involving hemolysis, elevated liver enzymes, and low platelet count. The pain and nausea are due to liver and gallbladder involvement. Placenta previa typically presents with painless vaginal bleeding, not upper quadrant pain. Hyperemesis gravidarum causes severe nausea and vomiting but not specific upper quadrant pain. Abruptio placentae presents with sudden-onset abdominal pain and vaginal bleeding.
Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)
- A. Risk for spiritual distress
- B. Risk for injury
- C. Readiness for enhanced nutrition
- D. Ineffective breathing pattern
Correct Answer: B
Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.
Which herbs would you counsel a lactating client to use to stimulate blood flow to the breast glands, stimulate milk production, and enrich milk flow?
- A. Milk thistle
- B. Cabbage juice
- C. Lanolin
- D. Aloe vera
Correct Answer: B
Rationale: The correct answer is B: Cabbage juice. Cabbage juice contains phytoestrogens that help stimulate blood flow to the breast glands and promote milk production. It is used traditionally to increase milk supply in lactating women. Milk thistle (A) is more commonly used for liver health and not specifically for lactation. Lanolin (C) is a topical ointment for sore nipples, not for milk production. Aloe vera (D) is not recommended for internal use during lactation due to potential laxative effects. In summary, cabbage juice is the best choice as it directly supports milk production and flow in lactating clients.