A client who was raped tells the nurse that she must not get ...

[imanialler]

A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate?
 
  A) The baby could always be given up for adoption.
  B) You will not know for sure for at least a few more days.
  C) There is a medication called Plan B, which is emergency contraception.
  D) Are you sure the rapist did not use a condom?

Question 2

The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply.
 
  A) Encourage the use of breathing, relaxation, and distraction.
  B) Encourage deep breathing and coughing every 2 to 4 hours.
  C) Encourage to ambulate to the bathroom to void.
  D) Discourage leg exercises.
  E) Withhold all analgesics.

[kxciann]

Answer to Question 1

Answer: C
Female rape victims may request information about emergency contraception if the attacker did not use a condom. Plan B (levonorgestrel) is available over the counter and may be made available to the client at the facility performing the examination following the attack. The nurse should discuss the medication Plan B with the client. The nurse should not tell the client that it will be a few more days to know for sure if she is pregnant. The nurse should not question whether the rapist used a condom. The client does not want to get pregnant. The nurse should not talk about giving a baby up for adoption at this time.

Answer to Question 2

Answer: A, B

Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients. Encouraging the client to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.