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A nurse is providing client teaching regarding an intrauterine device (IUD).

Which of the following statements should the nurse include in the teaching? (Select all that apply.)

A.

You might experience irregular spotting the first few months after placement of the device.

B.

You will need to avoid using tampons during menstrual cycles.

C.

You will need to sign informed consent prior to the procedure.

D.

The device will need to be replaced every 2 years.

Question Solution

Correct Answer : A,B,C

Choice A rationale

Irregular spotting is common after the placement of an IUD as the body adjusts to the device. This is a normal side effect and typically resolves within a few months.

 

Choice B rationale

Avoiding tampons initially after IUD placement is advised to prevent displacement or infection. Once the IUD is properly positioned and the risk of infection decreases, tampons can generally be used.

 

Choice C rationale

Informed consent is required prior to IUD placement to ensure the client understands the procedure, potential risks, and benefits, ensuring an informed decision.

 

Choice D rationale

IUDs typically need to be replaced every 3 to 10 years, depending on the type. Replacing an IUD every 2 years is not accurate and does not align with standard medical

recommendations.


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Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

Correct Answer is A

Explanation

Choice A rationale

A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.

Choice B rationale

Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.

Choice C rationale

Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.

Choice D rationale

A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).

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