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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
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What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
How can a nurse support a mother who has chosen not to breastfeed?
- A. Provide resources on breastfeeding benefits
- B. Provide formula samples for feeding
- C. Discuss the risks of formula feeding
- D. Support the mother’s feeding choice without judgment
Correct Answer: D
Rationale: The correct answer is D because it promotes non-judgmental support for the mother's decision. As a nurse, it is crucial to respect the mother's autonomy and decision-making. Providing resources on breastfeeding benefits (choice A) may come off as pressuring or judgmental. Offering formula samples (choice B) may not align with the mother's choice. Discussing risks of formula feeding (choice C) may create guilt or shame. Supporting the mother's feeding choice without judgment (choice D) encourages a positive and supportive environment for the mother.
What does intimate partner violence refer to?
- A. violence that occurs in public spaces, such as streets or parks, between acquaintances or strangers
- B. violence or abuse that occurs within a relationship, involving physical assault, sexual violence, emotional or psychologic abuse, controlling behaviors, and economic abuse
- C. violence primarily directed toward children by their parents or guardians
- D. violence that is limited to verbal arguments and does not involve physical harm
Correct Answer: B
Rationale: The correct answer is B because intimate partner violence refers to violence or abuse that occurs within a relationship, involving various forms of abuse like physical assault, sexual violence, emotional or psychological abuse, controlling behaviors, and economic abuse. This definition specifically highlights the nature of violence within the context of intimate relationships, distinguishing it from violence that occurs in public spaces (choice A), violence directed toward children (choice C), or limited to verbal arguments without physical harm (choice D). Choice A is incorrect as it focuses on violence between acquaintances or strangers in public spaces. Choice C is incorrect as it refers to violence toward children. Choice D is incorrect as it excludes physical harm, which is often a significant aspect of intimate partner violence.
A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
What do you give for magnesium sulfate toxicity?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Furosemide (Lasix)
- D. Vitamin K
Correct Answer: A
Rationale: The correct answer is A: Calcium gluconate. In magnesium sulfate toxicity, high levels of magnesium can lead to muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is given because it antagonizes the effects of magnesium on the neuromuscular system and helps prevent further complications. Sodium bicarbonate (B) is not the correct choice as it is used to treat acidosis, not magnesium toxicity. Furosemide (C) is a diuretic and would not address magnesium toxicity. Vitamin K (D) is used for blood clotting disorders, not for magnesium toxicity.