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A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
- A. Let me help you into a comfortable pushing position so you can begin bearing down.
- B. I am going to call the doctor to get a prescription for medication to ripen your cervix.
- C. I will give you some IV pain medicine to strengthen your contractions.
- D. Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client about the provider inserting an intrauterine pressure catheter to monitor contraction strength. This is appropriate because lack of cervical change in active labor could indicate inadequate contractions. Monitoring contraction strength with an intrauterine pressure catheter can help determine if the contractions are effective in progressing labor. It allows for more accurate assessment and timely interventions if needed.
Choice A is incorrect because pushing without adequate cervical dilation can lead to complications. Choice B is incorrect as medication to ripen the cervix is not indicated in this scenario. Choice C is incorrect as IV pain medicine does not address the issue of inadequate cervical change.
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A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions?
- A. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised
- B. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern.
- C. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation
- D. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation.
Correct Answer: B
Rationale: The correct answer is B because it recognizes that the man's actions may be influenced by his personality or cultural differences, rather than indicating a lack of concern. This choice acknowledges that individuals may react differently in stressful situations based on their upbringing, beliefs, or personal characteristics. This understanding is crucial for the nurse to provide appropriate support and address any potential misunderstandings.
Choice A suggests that the man's concern about the woman's health is compromising his ability to cope, which is not supported by the information provided. Choice C assumes the man's withdrawal is due to embarrassment and discomfort, which may not be the case. Choice D attributes the man's behavior to religious beliefs, which is not mentioned in the scenario. These choices do not align with the evidence presented and do not consider the complexity of human behavior in different contexts.
A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?
- A. Breastfeeding helps women lose weight faster.
- B. Breast milk contains a greater amount of protein.
- C. Breast milk is easier to digest than formula.
- D. Breastfeeding is a good method of contraception.
Correct Answer: C
Rationale: The correct answer is C: Breast milk is easier to digest than formula. Breast milk contains specific enzymes and antibodies that aid in digestion and are easily absorbed by the baby's immature digestive system. This promotes better nutrient absorption and reduces the risk of digestive issues. Option A is incorrect because weight loss varies for each woman and should not be the primary reason for breastfeeding. Option B is incorrect as breast milk has a balanced composition of nutrients, not just higher protein content. Option D is incorrect as breastfeeding is not a reliable form of contraception.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.
A nurse is reinforcing teaching with the parent of a child with a urinary tract infection.
- A. "I will bring my child to the bathroom before we leave for extended trips."'
- B. "I need to switch my child from cotton underwear to nylon underwear."'
- C. "I should teach my child to wipe from back to front after urinating."'
- D. "I will have my child soak in a bubble bath once or twice a week."'
Correct Answer: A
Rationale: Correct Answer: A. "I will bring my child to the bathroom before we leave for extended trips."
Rationale: Bringing the child to the bathroom before extended trips helps prevent urinary stasis and decreases the risk of urinary tract infections by promoting regular voiding. This practice ensures that the bladder is emptied regularly, reducing the chances of bacterial growth. It is important to encourage frequent urination to flush out bacteria and prevent infection.
Summary of other choices:
B: Switching from cotton to nylon underwear can increase moisture retention and promote bacterial growth, leading to an increased risk of urinary tract infections.
C: Teaching a child to wipe from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of urinary tract infections.
D: Soaking in a bubble bath can irritate the urethra and disrupt the natural balance of bacteria in the genital area, potentially leading to urinary tract infections.
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in a pregnant woman at 30 weeks gestation could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. It is important to report this finding promptly to the provider for further evaluation and management to prevent complications for both the mother and the baby. Varicose veins in the calves (B) and hyperpigmentation (D) are common in pregnancy but are not urgent issues requiring immediate reporting. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy but is not as concerning as facial swelling. Make sure to report any change in the severity of edema.