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A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: Correct Answer: D - Verify that informed consent is obtained prior to administration.
Rationale: Informed consent is a crucial ethical and legal requirement before any medical procedure. It ensures the client is aware of the risks, benefits, and alternatives to the treatment. Verifying informed consent protects the client's autonomy and prevents potential legal issues.
Incorrect Choices:
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for this procedure.
C: Instructing the client to avoid urinary elimination is unnecessary and could lead to discomfort and potential complications.
E, F, G: No additional choices provided, but they would likely be incorrect as well as they do not address the key safety and ethical considerations associated with administering dinoprostone insert for labor induction.
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A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps prevent aortocaval compression, a potential cause of hypotension after epidural anesthesia. When the client is lying on their back, the weight of the uterus can compress the vena cava, reducing venous return and cardiac output, leading to hypotension. Turning the client to a side-lying position relieves this compression, improving blood flow and helping to stabilize blood pressure.
Summary:
B: Applying oxygen may be beneficial in some cases, but it does not directly address the underlying cause of hypotension in this scenario.
C: Massaging the fundus is not indicated for hypotension following epidural anesthesia.
D: Assisting the client to empty their bladder may be important for overall comfort and prevention of complications, but it does not address the hypotension directly.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A. At 26 weeks of gestation, newborns are expected to have minimal arm recoil based on the New Ballard Score, as their muscle tone is typically low. This indicates immaturity and aligns with the developmental stage of a premature infant. The other choices are incorrect because: B: A popliteal angle of 90° is more indicative of a term infant. C: Creases over the entire foot sole are also seen in term infants, not premature infants. D: Raised areolas with 3 to 4 mm buds are associated with breast development in term infants, not preterm infants.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways
- B. Places the newborn in the crib in a prone position
- C. Offers the newborn a pacifier dipped in formula
- D. Prepares a bottle of formula mixed with rice cereal
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps provide comfort and bonding, mimicking the soothing motion in the womb. This action promotes a secure attachment between the guardian and the newborn. Placing the newborn in a crib in a prone position (B) is unsafe and increases the risk of sudden infant death syndrome (SIDS). Offering a pacifier dipped in formula (C) can introduce unnecessary calories and increase the risk of overfeeding. Preparing a bottle of formula mixed with rice cereal (D) is not appropriate for a newborn and can lead to digestive issues.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lay in a supine position throughout the test.
- C. You should not eat or drink for 2 hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being. Choice A is incorrect as the test duration varies. Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava. Choice C is incorrect as eating and drinking are not restricted before the test.