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A nurse is caring for a female client who requests a contraceptive diaphragm.

Which of the following actions should the nurse take first?

A.

Supervise return demonstration of diaphragm use.

B.

Determine the client’s knowledge about diaphragm use

C.

Document the client’s level of understanding about potential adverse effects.

D.

Teach the client how to insert the diaphragm

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.

Some of the other choices are wrong because:

  • Choice A. Supervise return demonstration of diaphragm use.

This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.

  • Choice C. Document the client’s level of understanding about potential adverse effects.

This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.

  • Choice D. Teach the client how to insert the diaphragm.

This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.

A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.

It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.

It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.


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Related Questions

Correct Answer is D

Explanation

The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.

This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.

Scheduled analgesics can provide better pain relief than PRN analgesics.

Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.

Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.

Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.

There is no indication that the child has asthma or needs this medication.

Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.

A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.

Correct Answer is D

Explanation

A. BP 150/92 mm Hg:

  • This blood pressure reading is elevated and not a therapeutic effect of magnesium sulfate. In the context of preeclampsia, the goal is usually to lower blood pressure to prevent complications.

B. Pulse rate 100/min:

  • The pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate. However, magnesium sulfate may cause a decrease in heart rate, so monitoring for bradycardia would be important.

C. Flushed face:

  • A flushed face is not a specific therapeutic effect of magnesium sulfate. Facial flushing may be associated with other factors, but it is not a primary consideration when monitoring the effectiveness of magnesium sulfate in the context of preeclampsia.

D. Negative clonus:

  • Negative clonus is the correct therapeutic effect to monitor. Clonus refers to a series of involuntary, rhythmic, and repetitive muscle contractions and relaxations. In the context of magnesium sulfate administration for preeclampsia, negative clonus (the absence of abnormal reflexes) is a sign that the magnesium levels are within the therapeutic range, helping to prevent seizures.

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