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A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
- A. Take the client's vital signs.
- B. Perform a Leopold's maneuver.
- C. Perform a manual sterile vaginal exam.
- D. Test the vaginal fluid with a Nitrazine strip.
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.
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The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?
- A. Flat on the operative side
- B. Flat on the unoperative side
- C. Prone with the head of the bed elevated
- D. Supine with the head of the bed elevated
Correct Answer: C
Rationale: After pyloromyotomy, the head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Based on this information, the remaining options are incorrect positions after this type of surgery. The surgeon's prescriptions for positioning should always be followed.
A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
- A. Assist the client in identifying supportive strategies.
- B. Initiate the possibility of placing the baby up for adoption.
- C. Stress the need for Alcoholics Anonymous (AA) meetings.
- D. Encourage the client to continue counseling after the birth.
- E. Encourage the client to participate in her rehabilitation care.
- F. Minimize communication with codependent family members.
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
- A. Allow the child to play loud music in the hospital room.
- B. Let the child wear his or her own clothing when friends visit.
- C. Allow the child to have his or her hair dyed if the parent agrees.
- D. Allow the child to keep the shades closed and the room darkened.
Correct Answer: B
Rationale: An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and to wear similar hairstyles. Loud music may disturb others in the hospital. Because Crutchfield traction involves the use of skeletal pins, hair dye is not appropriate. The child's request for a darkened room is indicative of a possible problem with depression that may require further evaluation and intervention.
The nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and should turn the suction to which setting?
- A. 60 mm Hg
- B. 90 mm Hg
- C. 110 mm Hg
- D. 120 mm Hg
Correct Answer: B
Rationale: The suctioning procedure for pediatric clients varies from that used for adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings as compared with those used for adults. Suction settings for a neonate are usually 60 to 80 mm Hg; for an infant, 80 to 100 mm Hg; and, for larger children, 100 to 120 mm Hg. The primary health care provider prescription and agency procedures are always followed.
The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
- A. Monitoring the temperature
- B. Monitoring the blood pressure
- C. Inspecting the anterior fontanel for bulging
- D. Monitoring the specific gravity of the urine
Correct Answer: C
Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.