Nokea
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 disordered eating?
- A. an occasional overeating episode
- B. a normal variation in eating patterns
- C. a range of abnormal eating behaviors and attitudes
- D. a preference for specific types of foods
Correct Answer: C
Rationale: The correct answer is C because disordered eating refers to a range of abnormal eating behaviors and attitudes that may indicate a potential eating disorder. This includes behaviors such as restrictive dieting, binge eating, purging, or obsessively controlling food intake. Option A is incorrect because an occasional overeating episode does not necessarily indicate disordered eating. Option B is incorrect as disordered eating is not considered a normal variation in eating patterns. Option D is incorrect as having a preference for specific types of foods does not classify as disordered eating unless it leads to serious negative consequences.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn during this procedure to prevent the spread of infection. The umbilical cord stump is a potential entry point for bacteria, so gloves are necessary to maintain asepsis.
A: Assisting a mother with breastfeeding does not require gloves as it is a clean procedure.
B: Performing a newborn's initial bath does not require gloves unless there are open wounds on the newborn.
C: Administering the measles, mumps, rubella vaccine may require gloves, but the primary concern is needlestick safety rather than infection control through glove use.
The nurse is teaching a client about postpartum care. Which statement indicates a need for further teaching?
- A. I will avoid heavy lifting for 6 weeks.
- B. It’s normal to have heavy bleeding for 4 weeks.
- C. I will call my doctor if I develop a fever.
- D. I should continue taking my prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because heavy bleeding for 4 weeks postpartum is abnormal and could indicate a complication. The client should seek medical attention if experiencing heavy bleeding beyond the normal range. Choices A, C, and D are all correct statements for postpartum care. A - avoiding heavy lifting helps prevent strain on healing tissues, C - fever could indicate infection, and D - continuing prenatal vitamins supports postpartum recovery.
In addition to the bolus of fluid which medication should she be given to increase blood pressure?
- A. Ephedrine
- B. Terbutaline
- C. Epinephrine
- D. Epifoam
Correct Answer: A
Rationale: The correct answer is A: Ephedrine. Ephedrine is a sympathomimetic amine that acts on alpha and beta adrenergic receptors to increase blood pressure. It is commonly used to treat hypotension. Terbutaline (B) and Epinephrine (C) are bronchodilators that can lower blood pressure. Epifoam (D) is a topical medication for skin conditions and does not affect blood pressure. Therefore, Ephedrine is the most appropriate choice to increase blood pressure in this scenario.
The nurse is assessing a client in labor with ruptured membranes. What finding indicates the need for immediate intervention?
- A. Temperature of 100.6°F.
- B. Clear amniotic fluid.
- C. Green, foul-smelling fluid.
- D. Client reports contractions every 5 minutes.
Correct Answer: C
Rationale: The correct answer is C: Green, foul-smelling fluid. This indicates meconium-stained amniotic fluid, which can be a sign of fetal distress and possible meconium aspiration. Immediate intervention is needed to prevent potential complications for the baby.
A: Temperature of 100.6°F could indicate maternal infection but does not require immediate intervention unless other signs are present.
B: Clear amniotic fluid is a normal finding.
D: Contractions every 5 minutes may indicate active labor, but it is not an immediate concern unless coupled with other signs of distress.