Which of the following nursing diagnoses is the priority after deliver

RN NCLEX Maternal Neonatal Nursing

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Question 1 of 5.

Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?

A. Pain related to episiotomy and exhaustive pushing efforts.

B. Anxiety related to inability to move legs and toes.

C. Risk for injury related to epidural anesthesia.

D. Excess fluid volume overload related to labor process and intravenous fluids.

Explanation: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.

Question 2 of 5.

After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?

A. I should perform breast self-examination on the day my menstrual flow begins.

B. It's important that I perform breast self-examination on the same day each month.

C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.

D. If there is discharge from my nipples, I should call my health care provider.

Explanation: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.

Question 3 of 5.

The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?

A. A slight drop followed by a rise in basal body temperature.

B. A change in cervical mucus to thin, clear, and stretchy.

C. The onset of mittelschmerz, or midcycle pelvic pain.

D. The presence of a thick, cloudy cervical mucus.

Explanation: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.

Question 4 of 5.

A client asks about the side effects of oral contraceptives. Which of the following would the nurse include in the response?

A. Weight loss is a common side effect.

B. Nausea and breast tenderness may occur initially.

C. Hair loss is frequently reported.

D. Oral contraceptives decrease the risk of breast cancer.

Explanation: Nausea and breast tenderness are common initial side effects of oral contraceptives, which often subside. Weight gain, not loss, may occur, hair loss is not typical, and oral contraceptives do not significantly reduce breast cancer risk.

Question 5 of 5.

A nurse is discussing sterilization options with a male client. Which of the following statements by the client indicates a need for further teaching?

A. A vasectomy involves cutting the vas deferens to prevent sperm release.

B. I will need to use another contraceptive method until my sperm count is zero.

C. A vasectomy will decrease my testosterone levels.

D. A vasectomy is considered a permanent form of contraception.

Explanation: A vasectomy does not decrease testosterone levels, as the testes continue to produce hormones. The other statements are correct, indicating a need for further teaching about hormonal effects.

Related Questions

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