A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?
Weight gain 2.3 kg (5 lb)
Frequent nausea
Breast tenderness
Persistent headache
The Correct Answer is D
A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.
B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.
C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.
D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.
B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.
C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.
D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.
Correct Answer is B
Explanation
Rationale:
A. Use a mummy restraint to hold the child during the catheter insertion: Physical restraints should be used only as a last resort, as they can increase anxiety and trauma. Non-pharmacologic methods and parental support are preferred for safely holding a child during procedures.
B. Perform the procedure in the child's room: Conducting the IV insertion in the child’s room helps reduce stress by providing a familiar environment. It also allows parental presence, which can comfort the child and improve cooperation.
C. Require the parents to leave the room during the procedure: Removing parents can increase the child’s anxiety and reduce emotional support. Parental presence is generally encouraged to help the child feel safe during invasive procedures.
D. Tell the child there will be discomfort during the catheter insertion: The nurse should provide age-appropriate explanations using simple, honest language, focusing on sensations rather than labeling it as painful, to reduce fear and encourage cooperation.
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