Nokea
While the nurse is assessing the fundus of a multiparous client who delivered 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?
- A. As long as you don't get pregnant again, the marks will disappear completely.
- B. They usually fade to a silvery-white color over a period of time.
- C. You'll need to use a specially prescribed cream to help them disappear.
- D. If you lose the weight you gained during pregnancy, the marks will fade to a pale pink.
Correct Answer: B
Rationale: Stretch marks typically fade to a silvery-white color over time without specific intervention.
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A client is considering the lactational amenorrhea method (LAM) for contraception. Which of the following conditions must be met for LAM to be effective?
- A. The client must be exclusively breastfeeding, amenorrheic, and less than 6 months postpartum.
- B. The client must be breastfeeding at least once daily and less than 12 months postpartum.
- C. The client must be amenorrheic and supplementing with formula.
- D. The client must be exclusively breastfeeding and have regular periods.
Correct Answer: A
Rationale: LAM is effective when the client is exclusively breastfeeding, amenorrheic, and less than 6 months postpartum, as these conditions suppress ovulation. The other options include factors that reduce its effectiveness, such as formula supplementation or regular periods.
A client asks the nurse about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods likeå®çŸ³
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant? Select all that apply.
- A. Removing a Foley catheter from a preeclamptic client.
- B. Assisting an active labor client with breathing and relaxation.
- C. Ambulating a postcesarean client to the bathroom.
- D. Calculating hourly I.V. totals for a preterm labor client.
- E. Intake and output catheterization for culture and sensitivity.
- F. Calling a report of normal findings to the health care provider.
- G. Removing lunch trays and documenting lunch intake.
Correct Answer: C,G
Rationale: Delegating ambulation and lunch tray removal is appropriate for a nursing assistant.
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
- A. Bronze-colored skin.
- B. Maculopapular chest rash.
- C. Urine specific gravity of 1.018.
- D. Absent Moro reflex.
Correct Answer: A
Rationale: Bronze-colored skin is a potential complication of phototherapy and should be reported to the health care provider.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?
- A. A required membranes.
- B. Multifetal gestation.
- C. Diabetes mellitus.
- D. Hypotonic labor patterns.
Correct Answer: A
Rationale: Jet hydrotherapy (e.g., whirlpool tubs) is contraindicated with ruptured membranes due to the risk of infection from water entering the vaginal canal. Multifetal gestation, diabetes, and hypotonic labor are not absolute contraindications unless other complications are present.