Nokea
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: Rationale: The correct answer is D. In the occipitoposterior position, the fetus's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can assess if the hands-and-knees position has helped relieve the pressure on the mother's sacrum, indicating effectiveness.
Incorrect Choices:
A: Suprapubic pain is not directly related to the occipitoposterior position or the hands-and-knees position.
B: Pelvic pressure may not necessarily be alleviated by changing positions in occipitoposterior position.
C: Contractions feeling further apart may not directly correlate with the effectiveness of the hands-and-knees position for back labor relief.
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A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
Correct Answer:
Rationale: Correct Answer: C: Get adequate rest and sleep
Rationale:
1. Sleep deprivation is a common trigger for postpartum depression.
2. Adequate rest and sleep help regulate mood and reduce stress levels.
3. Lack of sleep can worsen depressive symptoms.
4. Rest and sleep are essential for physical and emotional recovery postpartum.
Summary:
A: Engaging in physical activity is beneficial but not directly linked to preventing postpartum depression.
B: While a support system is important, it may not solely prevent postpartum depression.
D: Eating a well-balanced diet is crucial for overall health but not the primary focus for preventing postpartum depression.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and closure. It acknowledges the baby's existence and validates the client's experience. Choice A may be incorrect as it could deprive the client of the opportunity to spend time with their baby for closure. Choice C is incorrect as it may not be necessary in all cases and could be overwhelming for the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200Down Syndrome)
- B. Rust-stained urine
- C. Transient circumoral cyanosis
- D. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases (p200Down Syndrome). This is an important finding as it can indicate the presence of Down Syndrome in the newborn. It is important to report this to the provider promptly for further evaluation and management. Single palmar creases are not typically seen in healthy newborns.
Rust-stained urine (choice B) is likely due to urate crystals, which can be a normal finding in newborns and usually resolves on its own. Transient circumoral cyanosis (choice C) is common in newborns due to immature circulation and usually resolves without intervention. Subconjunctival hemorrhage (choice D) is also a common benign finding in newborns and usually resolves without treatment.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C - Hypotension
Rationale: Opioid analgesics can cause vasodilation leading to hypotension due to decreased systemic vascular resistance. The nurse should monitor the client for signs of hypotension such as lightheadedness, dizziness, and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications like decreased perfusion to vital organs.
Summary:
A: Hyperglycemia - Opioid analgesics do not typically cause hyperglycemia.
B: Bilateral crackles - This finding is more indicative of fluid overload or heart failure, not a direct effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not usually cause polyuria; in fact, they can cause urinary retention as a side effect due to bladder sphincter relaxation.