Nokea
The nurse in labor and birth is caring for a Muslim patient during the active phase of labor. The nurse notes that the patient quickly draws away when touched. Which intervention should the nurse implement?
- A. Ask the charge nurse to reassign you to another patient.
- B. Assume that she does not like you and decrease your time with her.
- C. Continue to touch her as much as you need to while providing care.
- D. Limit touching to a minimum because physical contact may not be acceptable in her culture.
Correct Answer: D
Rationale: The appropriate intervention for the nurse to implement in this situation is to limit touching to a minimum because physical contact may not be acceptable in the patient's culture. In Islam, modesty and privacy are significant aspects of the faith, and physical contact, especially with someone of the opposite gender, may be considered inappropriate or uncomfortable for the patient. Respecting and acknowledging the patient's cultural background and preferences is essential in providing culturally competent care. Therefore, it is important for the nurse to be mindful of the patient's boundaries and minimize any unnecessary physical contact while still providing necessary care and support during labor.
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The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called what?
- A. Bimanual palpation
- B. Rectovaginal palpation
- C. Papanicolaou (Pap) test
- D. Four As procedure
Correct Answer: C
Rationale: The Pap test is used to detect cancer and should be performed regularly depending on the client's age.
Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse first take when meeting with a new client to discuss contraception?
- A. Obtain data about the frequency of coitus.
- B. Determine the woman's level of knowledge concerning contraception and her commitment to any particular method.
- C. Assess the woman's willingness to touch her genitals and cervical mucus.
- D. Evaluate the woman's contraceptive life plan.
Correct Answer: B
Rationale: Determining the woman's level of knowledge about contraception and her commitment to a method is the first step. This provides the nurse with the necessary background before moving on to a diagnosis and appropriate method choices.
What type of mastectomy removes the entire breast but leaves the chest wall intact?
- A. total simple mastectomy
- B. modified radical mastectomy
- C. skin-sparing mastectomy
- D. nipple-sparing mastectomy
Correct Answer: A
Rationale: A total simple mastectomy is a type of mastectomy that removes the entire breast, including the breast tissue, nipple, and areola, but it leaves the chest wall muscles intact. In this procedure, the lymph nodes under the arm (axillary lymph nodes) are not typically removed. The total simple mastectomy is usually performed when the breast cancer is small and localized, and there is no evidence of spread to the surrounding lymph nodes or chest wall. This surgery is considered less extensive than other types of mastectomies, such as modified radical mastectomy, skin-sparing mastectomy, or nipple-sparing mastectomy, which involve different levels of tissue removal.
What is the goal of a long-term treatment plan for an adolescent with an eating disorder?
- A. Managing the effects of malnutrition
- B. Establishing sufficient caloric intake
- C. Improving family dynamics
- D. Restructuring client perception of body image
Correct Answer: D
Rationale: The primary focus of treatment is restructuring cognitive perceptions about the individual's body image, after reestablishing physiologic homeostasis.
A primipara patient asks about possible support options for her during the labor process. She is apprehensive that her family members will not be prepared to assist her during this time. Which option would be most effective for this patient?
- A. Reassure the patient that the labor and birth staff consists of highly trained nurses who are well educated to take care of laboring patients so that should be sufficient.
- B. Encourage the patient to take prepared childbirth classes with her husband because that should provide the best support by a family member.
- C. Provide information to the patient about obtaining a doula during the labor process.
- D. Tell the patient that this is a normal feeling based on fear of the unknown and that it will subside once she starts the labor process.
Correct Answer: C
Rationale: Providing information to the patient about obtaining a doula during the labor process is the most effective option in this scenario. A doula is a trained professional who provides physical, emotional, and informational support to the mother before, during, and after childbirth. They can help the mother feel supported and empowered during labor, especially if family members are unavailable or unprepared to offer the necessary support. Doulas can also help in communication with the medical staff, advocate for the mother's preferences, and provide comfort measures. Therefore, recommending the option of obtaining a doula would help address the patient's concerns about support during labor.