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A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack to the heel for 10 minutes prior to the puncture.
- B. Request a prescription for IM analgesic.
- C. Use a manual lancet to pierce the skin.
- D. Place the newborn skin-to-skin on the mother's chest.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother.
A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.
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A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?
- A. Administer ibuprofen 400 mg twice daily.
- B. Recommend that the client perform conscious relaxation techniques daily.
- C. Give the client ginseng tea with each meal.
- D. Instruct the client to soak in a bath with a water temperature of 105°F for 15 minutes daily.
Correct Answer: B
Rationale: The correct answer is B: Recommend that the client perform conscious relaxation techniques daily. Headaches during pregnancy can be common due to hormonal changes and increased blood volume. The nurse should recommend non-pharmacological interventions like relaxation techniques to manage headaches safely without medication. Conscious relaxation techniques can help reduce stress and tension, potentially alleviating headaches. Ibuprofen (choice A) is not recommended during pregnancy due to potential harm to the fetus. Ginseng tea (choice C) is not safe for pregnant women as it may lead to complications. Soaking in a hot bath (choice D) with a water temperature of 105°F can raise the body temperature, which is not advised during pregnancy as it may harm the baby.
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
A client who is at 22 weeks gestation is being educated by a nurse about the amniocentesis procedure. Which of the following statements should the nurse make?
- A. You will lie on your right side during the procedure.
- B. You should not eat anything for 24 hours before the procedure.
- C. You should empty your bladder before the procedure.
- D. The test is performed to determine gestational age.
Correct Answer: C
Rationale: The correct answer is C: You should empty your bladder before the procedure. This is important because a full bladder can obstruct the visualization of the fetus during amniocentesis. By emptying the bladder, the uterus is better positioned for the procedure, making it safer and more effective.
Explanation:
1. A (You will lie on your right side during the procedure) is incorrect because the position during amniocentesis is typically on the back or slightly tilted to the left.
2. B (You should not eat anything for 24 hours before the procedure) is incorrect as fasting is not required for amniocentesis.
3. D (The test is performed to determine gestational age) is incorrect as amniocentesis is used to detect genetic abnormalities, not gestational age.
A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct Answer: B
Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy.
1. Acknowledges client's emotions without judgment.
2. Validates the client's experience as common and normal.
3. Provides reassurance and support.
4. Encourages open communication.
Summary of Incorrect Choices:
A. Not necessary to escalate without client's consent.
C. Invalidates client's feelings and imposes expectations.
D. Implies assumption of severity and may be seen as intrusive.
A client in an obstetrical clinic is discussing using an IUD for contraception with a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?
- A. An IUD should be replaced annually during a pelvic exam.
- B. I cannot get an IUD until after I've had a child.
- C. I should plan on regaining fertility 5 months after the IUD is removed.
- D. I will check to ensure the strings of the IUD are still present after my periods.
Correct Answer: D
Rationale: The correct answer is D. Checking the strings of the IUD after periods ensures that the device is in place. This indicates understanding of IUD maintenance. Choice A is incorrect because IUDs usually last 3-10 years and do not need annual replacement. Choice B is incorrect because nulliparous women can also use IUDs. Choice C is incorrect as fertility typically returns quickly after IUD removal, not necessarily after 5 months.