Chapter 51: Birth Control

499. A patient calls a family planning clinic and tells the nurse that her vaginal ring, which has been in place for 2 weeks, came out sometime during the night while she was sleeping. The nurse will instruct her to: a. clean the ring with warm water, reinsert it, and use condoms for 7 days. b. discard the ring and insert a new ring after 1 week has passed. c. discard the ring and insert a new one to begin a new cycle. d. wash the ring in hot, soapy water, and reinsert it.

ANS: A If a ring is expelled before 3 weeks have passed, it can be reinserted after being washed in warm water. If the ring has been out longer than 3 hours, backup contraception should be used for 7 days. Because this ring was expelled while the patient was sleeping, using backup contraception is prudent. Discarding the ring is not indicated if it can be cleaned. The ring should not be washed in hot water.

509. A patient has just purchased a 1-year supply of 28-day-cycle oral contraceptives. She tells the nurse she wishes she had planned things better, because she has calculated that her period will begin during her upcoming honeymoon. What will the nurse suggest? a. She should discard the inert pills and start a new pack during the honeymoon. b. She should discontinue the oral contraceptives and use an alternative form of birth control. c. She should discuss a prescription for an extended-cycle product with her provider. d. She should discuss DMPA (Depo-Provera) injections in addition to the OC with her provider.

ANS: A OC users can achieve an extended-cycle schedule by discarding the inert pills and beginning a new pack for up to four cycles. It is not necessary to discontinue OCs. Because this woman has already purchased a 1-year supply, using the 28-day-cycle product as described is appropriate. If this woman opts for a long-term product, she should discontinue the OC.

512. A woman has been taking a progestin-only oral contraceptive and will begin using a vaginal ring. The nurse will teach the patient to insert the ring: a. the day the last pill is taken and use backup contraception for 7 days. b. 1 week before taking the last pill. c. 1 to 5 days after taking the last pill and use backup contraception for 2 days. d. within 7 days after taking the last pill.

ANS: A When patients who have been using a progestin-only OC begin using a vaginal ring, they should be instructed to insert the ring on the last day of the pill and use backup contraception for 7 days.

502. A patient at increased risk for thromboembolic disorders will begin taking a progestin-only oral contraceptive. Which statements by the patient indicates understanding of how this oral contraceptive works? (Choose 2) a. "I will need to use backup contraception if I miss a pill." b. "Irregular bleeding is an indication that I should stop using this drug." c. "The mini-pill is safer than combination OCs and is just as effective." d. "The progestin-only mini-pill will prevent me from ovulating."

ANS: A & C When a patient taking a progestin-only OC misses one or more pills, backup contraception should always be used for at least 2 days. Irregular bleeding occurs but is not an indication to stop using the drug, although many women do because of the inconvenience. The mini-pill is slightly safer than combination OCs and equally effective.

511. A patient who is taking a combination oral contraceptive begins taking carbamazepine. After several weeks, the patient tells the nurse she has begun experiencing spotting during her cycle. What will the nurse tell her to do? a. Change to condoms instead of oral contraceptives. b. Discuss an oral contraceptive with increased estrogen. c. Request a decreased dose of carbamazepine. d. Stop taking the oral contraceptive immediately.

ANS: B Carbamazepine induces hepatic cytochrome P450 and thus accelerates the metabolism of oral contraceptives. Spotting is a sign of reduced OC blood levels; patients experiencing this symptom may need an increased estrogen dose. If the dose of OC is not changed, the woman may use condoms along with the OC. Reducing the dose of carbamazepine is not correct. Discontinuing the OC immediately is not correct.

498. A patient is taking a combination oral contraceptive (OC) and tells the nurse that she is planning to undergo knee replacement surgery in 2 months. What will the nurse recommend for this patient? a. The patient should ask her provider about an OC with less progestin. b. The patient should discuss an alternative method of birth control prior to surgery. c. The patient should request an OC containing less estrogen after surgery. d. The patient should take the OC at bedtime after her surgery to reduce side effects.

ANS: B Patients taking an OC who undergo surgery in which immobilization increases the risk of postoperative thrombosis should stop taking the OC at least 4 weeks prior to surgery. The patient should discuss an alternate method of birth control with her provider. Estrogen, not progestin, increases the risk of thrombosis. The estrogen-containing OC should be stopped 4 weeks prior to surgery. Taking the OC at bedtime does not decrease the risk.

504. A patient has been taking a progestin-only, or "minipill," OC for 3 months and reports spotting and irregular menstrual cycles. The nurse will: a. question the patient about any possible missed doses of the pill. b. reassure the patient that this is normal with this form of contraception. c. recommend that she take a pregnancy test to rule out pregnancy. d. suggest that she use a backup form of contraception until these symptoms resolve.

ANS: B Patients taking the progestin-only OC may expect irregular bleeding, including spotting and irregular periods. This symptom does not indicate lack of compliance with the regimen. A pregnancy test is not indicated. It is not necessary to use a backup form of contraception.

500. An adolescent female patient with multiple sexual partners asks a nurse about birth control methods. The patient tells the nurse she tried oral contraceptives once but often forgot to take her pills. The nurse will recommend discussing which contraceptive method with the provider? a. An intrauterine device with a spermicide b. DMPA (Depo-Provera) and condoms c. Tubal ligation and condoms d. Progestin-only oral contraceptives

ANS: B This patient has demonstrated a previous history of nonadherence, so a long-acting contraceptive would be more effective for her. Because she has multiple sexual partners, she should use a condom for protection against STDs. An IUD is not indicated for her; patients with multiple sexual partners who use IUDs are at greater risk for STDs. Tubal ligation carries surgical risks and should not be used by young women because it is irreversible. Progestin-only oral contraceptives must be taken every day.

505. A patient has been experiencing side effects with a combination oral contraceptive, and her provider has ordered a different combination product. The nurse will instruct the patient to do what? a. Begin taking the new product immediately. b. Change products at the beginning of her next cycle. c. Stop taking the old OC 1 week before starting the new OC. d. Use an alternate method of contraception for 1 month before starting the new OC.

ANS: B When changing one combination OC for another, the change is best made at the beginning of a new cycle. It is not correct to begin taking the new product immediately; to stop the old product 1 week before starting the new product; or to use an alternate method of birth control between regimens.

507. A patient is taking a combination oral contraceptive (OC) and reports breast tenderness, edema, and occasional nausea. What will the nurse recommend? a. The patient should ask her provider about an OC with less progestin. b. The patient should discuss an alternate method of birth control. c. The patient should request an OC containing less estrogen. d. The patient should take the OC at bedtime to reduce side effect

ANS: C Breast tenderness, edema, and nausea are associated with estrogen; women experiencing these side effects may benefit from an OC with a lower estrogen dose. Lowering the progestin will not decrease these symptoms. It is not necessary to change birth control methods if side effects can be managed by altering the estrogen dose. Taking the OC at bedtime will not affect the symptoms.

503. A nurse is discussing various ways to obtain a medical abortion with a patient. Which statement by the patient best demonstrates understanding of mifepristone (RU 486) [Mifeprex]? "This drug is most effective if I use it: a. before the first missed menstrual period." b. the day after unprotected intercourse." c. within 7 weeks of conception." d. immediately after ovulation."

ANS: C Mifepristone is most effective if it is used within 7 weeks of conception. The timing specified in the other responses is incorrect.

513. A nurse is teaching an adolescent female patient about 28-day monophasic combination oral contraceptives. The provider has instructed the patient to begin taking the pills on the first Sunday after the onset of her next period. What will the nurse tell the patient? a. "If breakthrough spotting occurs, you should begin taking a new pack of pills." b. "Protection from pregnancy will begin immediately." c. "Use another form of contraception for the next month." d. "You may take the pills at different times of day."

ANS: C When beginning oral contraceptives, it is important that the patient use another form of contraception for the first month, because protection is not immediate. Breakthrough spotting is common and is not an indication for starting a new cycle. Protection from pregnancy is not immediate. It is important to take the pills at the same time each day.

501. A nurse working in a family planning clinic is teaching a class on intrauterine devices (IUDs). Which patient should be advised against using an IUD for contraception? a. A 45-year-old married woman with four children. b. A 30-year-old monogamous married woman. c. An 18-year-old woman with multiple sexual partners. d. A 35-year-old woman with a history of rosacea.

ANS: C Women at risk for sexually transmitted diseases (STDs) should not use an IUD, because the risk of infection is higher. Women who have multiple sexual partners are especially at risk for STDs. Monogamous married women are less apt to contract STDs. Women with rosacea can use an IUD.

508. A patient calls the nurse to report that she forgot to take a combination OC pill during the third week of her cycle. She tells the nurse that she missed another pill earlier that week. The nurse will tell her to: a. continue the pack, skip the inert pills, and use an additional form of contraception for 7 days. b. not to worry, because up to 7 days can be missed without an increased risk of pregnancy. c. take a pill immediately, continue the pack, and use an additional form of contraception for 1 month. d. take a pill now, continue the pack, skip the placebo pills, and start a new pack on week 4.

ANS: D If one or two pills are missed during the second or third week of a 28-day cycle, the patient should be instructed to take one pill as soon as possible, continue the pack, skip the placebo pills, and go straight to a new pack. It is not necessary to use an alternative form of contraception. If three or more pills are missed, the risk of pregnancy increases.

506. A nurse is teaching a community education class on contraceptives. The nurse tells the class that if spermicides containing nonoxynol-9 are used, the patient should take special precautions, because these spermicides have been linked to: a. human papillomavirus (HPV) infections. b. spontaneous abortions. c. endometrial cancer. d. increased transmission of the human immunodeficiency virus (HIV).

ANS: D Spermicides that contain nonoxynol-9 have been linked to the increased transmission of HIV. Spermicides containing nonoxynol-9 have not been linked to HPV infections, spontaneous abortions, or endometrial cancer.

510. A nurse working in a family planning clinic is preparing to administer a first dose of intramuscular DMPA [Depo-Provera] to a young adult patient. The woman tells the nurse she has just finished her period. What will the nurse do? a. Administer the injection today and counsel backup contraception for 7 days. b. Administer the injection today and tell her that protection is immediate. c. Obtain a pregnancy test to rule out pregnancy before administering the drug. d. Schedule an appointment for her to receive the injection in 3 weeks.

ANS: D To ensure that patients are not pregnant when they receive DMPA, the first injection should be given during the first 5 days of a normal menstrual period.