A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?
"You should avoid vaginal spermicides while breastfeeding."
"The lactation amenorrhea method is effective for your first year postpartum."
"Place the transdermal birth control patch on your upper outer arm."
"You can continue to use the diaphragm you used before your pregnancy."
The Correct Answer is C
Rationale:
A. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides are generally considered safe during breastfeeding. They do not contain hormones and do not affect milk production, so avoidance is not typically necessary unless the client has specific contraindications.
B. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective during the first 6 months postpartum, provided the mother is exclusively breastfeeding and menstruation has not resumed. Beyond that period, the risk of ovulation increases and it becomes unreliable.
C. "Place the transdermal birth control patch on your upper outer arm.": The patch can be applied to several sites, including the upper outer arm, abdomen, buttock, or upper torso. This is an appropriate instruction and part of standard patient teaching for transdermal contraceptive use.
D. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm often requires refitting postpartum due to changes in vaginal tone and cervix position. Using the same diaphragm without evaluation could reduce effectiveness and increase risk of unintended pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Rationale for Correct Choices:
- Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
- Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.
Rationale for Incorrect Choices:
- Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
- Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
- Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.
Correct Answer is ["B","C"]
Explanation
Rationale:
A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.
B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.
C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.
D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.
E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.
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