The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?

Correct Answer: C

Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.

Correct Answer: B

Rationale: The correct answer is B: Variable decelerations on the fetal monitor. This finding suggests umbilical cord prolapse because the cord can become compressed during contractions, leading to variable decelerations. It is a serious complication that requires immediate intervention to prevent fetal distress. A: Clear amniotic fluid is a normal finding after rupture of membranes. C: Contractions every 2 minutes may indicate tachysystole, but not specifically cord prolapse. D: Maternal blood pressure is not directly related to cord prolapse.

Correct Answer: A

Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication. Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection. Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method. Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.

Correct Answer: B

Rationale: The correct answer is B: Neck. The patch contraception is most effective when applied to a clean, dry, and hairless area of the body. The neck is a suitable site because it is easily accessible, non-occlusive, and less likely to be affected by clothing friction. Placing the patch on the neck also helps avoid skin irritation and allows for optimal absorption of hormones. Choice A: Buttocks - The buttocks may not be an ideal site as it can be covered by clothing and may not allow for proper adherence and absorption. Choice C: Leg - The leg is not typically recommended as a site for the patch due to movement and friction from clothing that may affect patch adhesion and hormone absorption. Choice D: Arm - While the arm is a possible site for the patch, it is not as ideal as the neck because it may be subject to more movement and rubbing against clothing, potentially affecting patch adherence and effectiveness.

Correct Answer: C

Rationale: The correct answer, C, states that excess spermicide should be removed from the vagina within 6 hours to reduce vaginal irritation. This is important as leaving excess spermicide can lead to discomfort and irritation. It is a crucial instruction to ensure the user's comfort and safety. Choice A is incorrect as nonoxynol-9 does not necessarily increase efficacy when used with barrier methods. Choice B is incorrect because while using spermicide with condoms can reduce the risk of STIs, the statement does not specifically address the instructions for use. Choice D is incorrect as placing the spermicide close to the vagina's opening does not guarantee maximal effectiveness and is not a critical instruction for safe use.