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 ["A","B","C","D","F","G"]
Explanation
Rationale:
A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.
B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.
C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.
D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.
E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.
F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.
G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.
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