Nokea
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who smokes one pack of cigarettes per day
- B. A client who has a history of gallbladder disease
- C. A client who has a positive pregnancy test
- D. A client who is nulliparous
Correct Answer: C
Rationale: An IUD should not be inserted in a client who has a positive pregnancy test. Inserting an IUD during pregnancy can lead to complications such as infection, miscarriage, and preterm birth. It is crucial to confirm the absence of pregnancy before IUD insertion.
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A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I have contractions more often than every 10 minutes, might be in preterm labor.
- B. I can take a daily iron supplement to prevent preterm labor.
- C. I should expect to feel pain in my upper right abdomen if I'm having preterm labor.
- D. I might be experiencing preterm labor if walking stops my contractions.
Correct Answer: A
Rationale: Contractions occurring more frequently than every 10 minutes can be a sign of preterm labor and should prompt the client to seek medical attention, indicating an accurate understanding of preterm labor warning signs.
A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Lie in a left side lying position for 30 min after meals
- B. Drink a cup of black coffee before breakfast
- C. Take sips of milk between meals
- D. Eat three large meals per day
Correct Answer: C
Rationale: Taking sips of milk between meals can help neutralize stomach acid and provide temporary relief from heartburn symptoms. However, it's essential to avoid drinking large quantities of milk at once, as this can lead to increased stomach acid production.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Weigh the newborn's wet diaper.
- B. Determine the newborn's respiratory rate.
- C. Auscultate the newborn's bowel sounds.
- D. Swaddle the newborn impretermn blankets.
Correct Answer: B
Rationale: Determining the respiratory rate is critical first, as neonatal abstinence syndrome can cause respiratory distress, requiring immediate intervention for the newborn's safety.
A nurse is transporting a newborn to their parents from the nursery. Which of the following actions should the nurse perform to confirm the newborn's identity?
- A. Ask a parent to state the newborn's date of birth.
- B. Check the newborn's footprint sheet with the medical record.
- C. Request a parent to verify the newborn's name.
- D. Compare numbers on the newborn's band to the parent's band.
Correct Answer: D
Rationale: Comparing the identification numbers on the newborn's band with the parent's band is the most reliable method to confirm identity, ensuring the newborn is matched with the correct parent(s) and preventing mix-ups or abduction.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will apply vitamin E oil to my nipples after each feeding.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Using a pillow to support the baby at breast level ensures proper positioning and latch, making breastfeeding more comfortable and effective, indicating understanding of the teaching.