NUR 113 WRAP 1
The nurse is assessing a client who presents with an open sore on his penis. Which question by the nurse best elicits additional data related to this finding? A. "Do you think you have a disease?" B. "Are you promiscuous?" C. "Have you had sexual intercourse recently?" D. "When did you initially notice this open area?"
D
A nurse is caring for a client who wants more information about fertility awareness-based contraceptive methods. Which statement made by the nurse provides the client with correct information? A. "To use the calendar rhythm method, a woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles." Your answer is correct. B. "The calendar method is the most reliable fertility awareness-based method of contraception." C. "For women, the fertility window occurs between days 19 and 26 of the menstrual cycle." D. "The calendar rhythm method is based on the assumption that ovulation tends to occur about 7 days before the start of a woman's next menstrual period."
A
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A. Beginning continuous fetal heart rate monitoring B. Administering oxygen at 2 liters per minute C. Notifying the healthcare provider that birth is imminent D. Changing the client's position in bed
A
When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? A. Ask the client to void and then reassess fundal height. B. Ask another nurse to assess the client to verify the findings. C. Notify the client's midwife of this condition. D. Perform a straight catheterization on the client and then reassess fundal height.
A
Which of the following statements is true with regard to women's sexual health during the postpartum period? A. Women who use diaphragms as their primary means of contraception should be refitted for these devices no more than 6 weeks after giving birth. Your answer is correct. B. Hormonal contraceptives can affect the quantity and quality of breast milk and increase the risk for deep vein thrombosis (DVT) if used in the first month after giving birth. C. Condoms and spermicides should not be used for contraception in the immediate postpartum period, because they increase a woman's risk for uterine infection. D. The lactational amenorrhea method is the most reliable form of contraception during the postpartum period, but only if a woman is breastfeeding exclusively.
A
The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply. A. Encourage deep breathing and coughing every 2 to 4 hours. B. Encourage the use of breathing, relaxation, and distraction. C. Encourage to ambulate to the bathroom to void. D. Withhold all analgesics. E. Discourage leg exercises.
A B
The nurse is conducting a history and physical assessment of a sexually active teenage client. Which findings should the nurse identify as consistent with genital herpes? Select all that apply. A. Dysuria B. Fever C. Vaginal discharge D. Headache E. Low blood pressure
A B C D
A client is prescribed an oral contraceptive that contains estrogen and progesterone. What information should the nurse include when educating the client about this contraceptive? Select all that apply. A. Breast tenderness may occur when taking oral contraceptives that contain estrogen. Your answer is correct. B. The estrogen portion of the contraceptive may cause an increase in appetite and subsequent weight gain. C. Acne and oily skin are common side effects of the progesterone component in combined oral contraceptives. Your answer is correct. D. The progesterone portion of the contraceptive may cause headaches and nausea. E. Taking an oral contraceptive that contains progesterone can lead to an increase in blood pressure.
A C
A female client tells the nurse she would like to wait to start a family, even though her partner seems interested in having children in the near future. The client then asks the nurse what she should do. Which response from the nurse is best? A. "What would you do if you became pregnant now?" B. "You and your partner need to discuss the decision to start a family." C. "Maybe you should babysit a friend's child for a while to see whether you really want children." D. "If you don't want to start a family, then you don't have to."
B
Upon delivery of the newborn, which nursing intervention promotes parental attachment? A. Taking the newborn to the nursery for the initial assessment B. Placing the newborn on the maternal chest C. Placing the newborn on the bed next to the mother D. Placing the newborn under the radiant warmer
B
A client wants to use the vaginal sponge as a method of contraception. Which statements indicate that the client needs further instruction about use of this method? Select all that apply. A. "I can insert the sponge up to 24 hours before having sex." B. "I need to add spermicidal cream to the sponge prior to having sex." C. "I need to use a lubricant prior to insertion of the sponge." D. "I need to moisten the sponge with water prior to use." E. "I should never leave the sponge in for more than 6 hours."
B C E
A public health nurse is educating a group of adults about the incidence and prevalence of sexually transmitted infections (STIs). Which statement should be included? A. "Men are disproportionately affected by STIs as compared to women and infants." B. "The incidence of STIs is highest among young Caucasian females." C. "Women often experience few early manifestations of infection, which causes them to delay diagnosis and treatment." D. "Males have higher rates of gonorrhea and chlamydia, whereas women have higher rates of syphilis."
C
A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A. Fear B. Anxiety C. Acute Pain D. Health-Seeking Behaviors
C
A client tells the nurse she plans to use oral contraceptives for birth control. Given this information, which client behavior would cause the nurse the most concern? A. The client has several sexual partners. B. The client is being treated for bipolar disorder. C. The client smokes a pack of cigarettes each day. Your answer is correct. D. The client drinks two glasses of wine per day.
C
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A. Applying oxygen via mask at 10 liters per minute B. Preparing for imminent delivery C. Documenting the fetal heart rate D. Assisting the client into the Fowler position
C
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A. "During labor, the nurse will regularly check my cervix by doing a pelvic exam." B. "During labor, the nurse will look at the color and amount of bloody show that I have." C. "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D. "During labor, the nurse will verify that my contractions are strong but not too close together."
C
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A. Encouraging the client to void every 1-2 hours B. Administering antibiotics for a positive group beta strep C. Assessing fetal heart rate every 5 minutes Your answer is correct. D. Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured
C
The nurse is providing education to sexual partners about the importance of treatment for a chlamydia infection. Which client statements indicate this teaching was effective? Select all that apply. A. "Severe vaginal itching can be a consequence of chlamydia." B. "Rashes commonly occur with this disease." C. "Chlamydia can spread to the uterus and fallopian tubes and result in infertility." Your answer is correct. D. "Chlamydia can cause inflammation of the tube that carries urine from the bladder to outside the body." E. "Chlamydia can result in pregnancy complications."
C D E
The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply. A. Restrict interactions with the client. B. Limit client visitors to the immediate family. C. Assess for any specific foods or fluids to hasten recovery. D. Assess for any assistance required during breastfeeding. E. Ask if there are any specific customs the client wants to follow.
C D E
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? A. Fundus at the umbilical level B. Firm fundus C. Moderate lochia rubra D. Steady trickle of blood
D