A nurse is caring for a client who inquires about available methods of contraception.Which of the following actions should the nurse take?
Assess the client’s socioeconomic status.
Select the best method of contraception for the client.
Perform unbiased teaching.
Provide information on all available methods.
The Correct Answer is C
Choice A rationale
Assessing the client’s socioeconomic status is important for understanding their overall health and access to resources, but it is not directly related to providing information about contraception.
Choice B rationale
Selecting the best method of contraception for the client is not the nurse’s role. The decision should be made by the client based on their individual preferences and health considerations.
Choice C rationale
Performing unbiased teaching is essential for providing accurate and comprehensive information about available methods of contraception. The nurse should present all options without imposing personal beliefs or preferences.
Choice D rationale
Providing information on all available methods is important, but it should be done in an unbiased manner. The nurse should ensure that the client has all the necessary information to make an informed decision.
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Correct Answer is C
Explanation
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
Correct Answer is D
Explanation
Choice A rationale
Tingling in the fingers, also known as carpal tunnel syndrome, is more commonly associated with the later stages of pregnancy when fluid retention is more pronounced. It is not typically a common discomfort during the first trimester.
Choice B rationale
Round ligament pain is more common in the second trimester when the uterus is growing rapidly and the ligaments supporting it stretch. This type of pain usually manifests as sharp, shooting pain in the lower abdomen or groin.
Choice C rationale
Perineal discomfort and pressure are more common in the later stages of pregnancy, particularly in the third trimester, as the baby descends into the pelvis and prepares for birth. It is not typically a discomfort experienced during the first trimester.
Choice D rationale
Increased urgency and frequency of urination are common discomforts during the first trimester of pregnancy. This occurs due to hormonal changes and the growing uterus pressing on the bladder, which reduces its capacity.