Nokea
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used to induce ovulation in women experiencing infertility. Breast tenderness is a common adverse effect due to the hormonal changes caused by the medication. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly associated with ototoxic medications, urinary frequency may be seen with diuretics, and chills are usually a symptom of infections or fevers.
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A client with a history of hypertension is at 28 weeks' gestation. What complication is she at greatest risk for?
- A. Placenta previa.
- B. Gestational diabetes.
- C. Abruptio placentae.
- D. Preterm labor.
Correct Answer: C
Rationale: The correct answer is C: Abruptio placentae. At 28 weeks, the client with hypertension is at greater risk for abruptio placentae due to increased vascular resistance, leading to potential placental detachment. Placenta previa (A) is more common in the third trimester. Gestational diabetes (B) is more common in later pregnancy and not directly related to hypertension. Preterm labor (D) can be a risk with chronic hypertension but is not the greatest risk at 28 weeks.
The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.
The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
What is one difference between the copper IUC and the LNG-IUC?
- A. efficacy
- B. placement in the uterus
- C. presence of a normal period
- D. shape
Correct Answer: B
Rationale: The correct answer is B: placement in the uterus. The copper IUC and LNG-IUC differ in where they are positioned in the uterus. The copper IUC is a T-shaped device placed in the uterus to prevent pregnancy through copper ions, while the LNG-IUC releases hormones and is also placed in the uterus but is a different shape, typically a smaller T or a rounded shape. The placement of the device is crucial for its effectiveness and type of hormone release. Other choices (A) efficacy, (C) presence of a normal period, and (D) shape, do not directly differentiate between the two types of IUCs.