Nokea
A nurse is caring for a client who inquires about available methods of contraception.
Which of the following actions should the nurse take?
- A. Collect a dietary history.
- B. Assess the client's socioeconomic status.
- C. Perform unbiased teaching.
- D. Select the best method of contraception for the client.
Correct Answer: C
Rationale: Performing unbiased teaching provides comprehensive contraception information, empowering the client to make an informed decision autonomously.
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A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Catheterize the client's bladder.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Offer an ice pack to the client during the first 24 hours.
- D. Increase the client's fluid intake for 48 hours.
Correct Answer: C
Rationale: Offering an ice pack reduces swelling and numbs perineal pain, a standard intervention within the first 24 hours post-delivery.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever.
- B. Diarrhea.
- C. Sedation.
- D. Diuresis.
Correct Answer: C
Rationale: Sedation is a known adverse effect of nalbuphine hydrochloride, an opioid analgesic that depresses the central nervous system, causing drowsiness.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
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. Swaddle the newborn in blankets.
- B. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Tachypnea.
- B. Hyporeflexia.
- C. Agitation.
- D. Polyuria.
Correct Answer: B
Rationale: Hyporeflexia indicates magnesium sulfate toxicity, a serious adverse effect requiring immediate reporting to prevent respiratory or cardiac issues.