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A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care after birth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:
- A. Demonstrate appropriate coping mechanisms needed to get through the surgery.
- B. Accept that the type of delivery will not affect the bonding with the baby.
- C. Verbalize understanding about the reason for the unplanned surgery.
- D. Demonstrate decreased anxiety and fear of the unknown.
Correct Answer: C
Rationale: The correct answer is C: Verbalize understanding about the reason for the unplanned surgery. This outcome focuses on the client understanding why the cesarean delivery is necessary, which is crucial for informed decision-making and reducing anxiety. It shows the client comprehends the situation, which is important for her emotional well-being and cooperation during the procedure and postpartum period. Option A is incorrect because coping mechanisms are important but not directly related to knowledge deficit correction. Option B is incorrect as it does not address the client's knowledge deficit but rather focuses on emotional aspects. Option D is incorrect as it addresses anxiety and fear but not the underlying issue of knowledge deficit.
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The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
- A. Check the client's capillary refill and oxygenation.
- B. Monitor the maternal pulse and blood pressure.
- C. Inspect the perineum for lacerations, bleeding, and hematoma.
- D. Assess the fluid for color, odor, and amount.
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is important to assess the amniotic fluid to ensure it is clear, odorless, and of the appropriate amount, as changes in these characteristics may indicate fetal distress or infection. Checking capillary refill and oxygenation (Choice A) is not directly related to an amniotomy. Monitoring maternal pulse and blood pressure (Choice B) is important but not the immediate priority post-amniotomy. Inspecting the perineum for lacerations, bleeding, and hematoma (Choice C) is important for overall assessment but not specific to the procedure.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
- A. You can miss your period for several other reasons, describe your typical menstrual cycle.
- B. If you have been sexually active and haven't used protection, it is likely that you are pregnant.
- C. Let's check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
- D. Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Response A is the most appropriate because it addresses the client's concerns while also gathering more information. By asking the client to describe her typical menstrual cycle, the nurse can explore other potential reasons for the missed period, such as stress or hormonal imbalances. This approach shows empathy and helps the nurse to provide personalized care based on the client's individual situation.
Summary of Other Choices:
B: This response assumes pregnancy without gathering more information or considering other possibilities, potentially causing unnecessary worry or anxiety.
C: Asking about abdominal enlargement is a specific sign of pregnancy and may not be relevant at this early stage. It also does not address the client's anxiety directly.
D: While suggesting a home pregnancy test is important, it does not address the client's anxiety or gather more information about her menstrual cycle.
A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.