Nokea
Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
- A. An intrauterine device (IUD)
- B. Depot-medroxyprogesterone acetate injections
- C. A female condom with nonoxynol-9
- D. A diaphragm
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
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The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
- A. Transition
- B. Active
- C. Active pushing
- D. Latent
Correct Answer: D
Rationale: During the latent phase (1—3 cm), the client is usually happy and talkative. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more likely to lose control. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative.
Which fetal heart rate must the nurse report immediately to the physician?
- A. 100 beats/minute
- B. 120 beats/minute
- C. 140 beats/minute
- D. 160 beats/minute
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.
When providing information about iron supplements, which instruction by the nurse is most appropriate?
- A. Take the supplement with meals.
- B. Take the supplement with orange juice.
- C. Increase your intake of dairy products.
- D. You can substitute dietary sources of iron for this medication.
Correct Answer: B
Rationale: Taking iron with orange juice (rich in vitamin C) enhances absorption, addressing the client's constipation concern.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?
- A. “You need to come to the clinic as soon as possible.”
- B. “You’ll need an antibiotic; which pharmacy do you use?”
- C. “Take your temperature and let me know if it is elevated.”
- D. “A creamy white discharge 10 days postpartum is normal.”
Correct Answer: D
Rationale: There is no need to be seen in the clinic; vaginal discharge that turns creamy white 10 days postpartum is normal. The client does not have an infection, and no antibiotic is necessary. There is no reason to take her temperature when the discharge is normal. Creamy white discharge 10 to 21 days postpartum is normal. Her lochia changed color on her 10th postpartum day.