A nurse is caring for a client. Click to highlight the findings that are contraindications to the use of a combined oral contraceptive. To deselect a finding, click on the finding again. History and Physical 1 year ago: 33-year-old client here for routine physical examination and is requesting contraception until they attempt to conceive in about a year. Client has diabetes mellitus, diagnosed 24 years ago. Care is managed by an endocrinologist, has an insulin pump. States HbA1c was 6.7% last month. Client also has migraine headaches with aura and gastroesophageal reflux disease. Client is a lifetime nonsmoker, reports rarely drinking alcohol. Client is a law enforcement officer and works full time. Reports exercising three or four times per week, usually walking for 2 to 3 miles or riding a stationary bike. Client had a tonsillectomy at 6 years of age. Also had a deep vein thrombosis while travelling internationally 5 years ago.

Rationale for correct choices • Migraine headaches with aura: Combined oral contraceptives (COCs) increase the risk of ischemic stroke in individuals with migraine with aura. Estrogen-containing contraception can exacerbate cerebrovascular risk, making it a contraindication regardless of age or other vascular risk factors. Even with good glycemic control, the presence of aura elevates stroke risk significantly. • History of deep vein thrombosis: COCs increase the risk of venous thromboembolism (VTE). A previous DVT is a strong contraindication because estrogen-containing contraceptives can trigger recurrence. Even if the event occurred years ago, the risk remains elevated, particularly in the presence of other risk factors such as immobility or hypercoagulable states. • Diabetes mellitus (long-standing): Although the client currently has well-controlled blood sugar (HbA1c 6.7%), the duration of diabetes (24 years) significantly increases the risk of cardiovascular disease. Estrogen-containing contraceptives further elevate cardiovascular and thrombotic risk, making long-standing diabetes a relative contraindication. Rationale for incorrect choices • Lifetime nonsmoker / Rare alcohol use: Non-smoking status reduces cardiovascular risk, which is protective rather than contraindicating. Alcohol use in small amounts does not increase risk significantly.