Nokea
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
- A. Limiting fluid intake to 1 L daily to prevent overload.
- B. Catheterizing the bladder every 2 to 4 hours while awake.
- C. Washing the perineum with povidone iodine (Betadine) after voiding.
- D. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
Correct Answer: D
Rationale: Avoiding acidic juices reduces bladder irritation during cystitis treatment.
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A nurse is discussing the copper IUD with a client. Which of the following side effects should the nurse mention?
- A. Decreased menstrual bleeding.
- B. Increased menstrual bleeding and cramping.
- C. Permanent infertility.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The copper IUD may increase menstrual bleeding and cramping, especially initially. It does not decrease bleeding, cause permanent infertility, or guarantee regular periods.
The physician orders 1000 mL of Ringer's Lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute?
- A. 25 gtts/minute.
- B. 30 gtts/minute.
- C. 35 gtts/minute.
- D. 40 gtts/minute.
Correct Answer: A
Rationale: Calculation: (1000 mL * 12 gtts/mL) / (8 hours * 60 minutes) = 25 gtts/minute.
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
- A. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy.
- B. I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Sperm can reach the ovum in 15-30 minutes under ideal conditions, which is accurate. Abstaining during the last 14 days of the cycle is not a reliable contraception method, as ovulation timing varies.
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
- A. It's of no concern because it is such a small amount.
- B. The cause is usually related to swallowing blood during the delivery.
- C. Sometimes baby girls have this from hormones received from the mother.
- D. This vaginal spotting is caused by hemorrhagic disease of the newborn.
Correct Answer: C
Rationale: Pseudo-menstruation in female newborns is due to maternal hormone withdrawal.
The nurse is explaining to a primagravida in labor that her baby is in a breech presentation, with the baby’s presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned?
- A. primagravida-1.png
- B. primagravida-2.png
- C. primagravida-3.png
- D. primagravida-4.png
Correct Answer: A
Rationale: This figure shows the client’s baby in a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA). Figure 3 shows a vertex presentation, left, occipit, posterior (LOP). Figure 4 shows a face position with the babyin a left, mentum, transverse position (LMT).