Nokea
A nurse is caring for a client who is in the transition phase of labor. Which of the following...
- A. Assist the client to void every 3 hr.
- B. Monitor contractions every 30 min.
- C. Place the client into a lithotomy position.
- D. Encourage the client to use a pant-blow breathing pattern.
Correct Answer: B
Rationale: The correct answer is B: Monitor contractions every 30 min. During the transition phase of labor, contractions are typically intense and frequent. Monitoring contractions every 30 minutes allows the nurse to assess the progress of labor and ensure the safety of both the mother and the baby. This helps in identifying any abnormalities or complications that may arise during this critical stage.
A: Assisting the client to void every 3 hr is important, but it is not specific to the transition phase of labor.
C: Placing the client into a lithotomy position is not recommended during the transition phase as it can restrict blood flow and increase the risk of complications.
D: Encouraging the client to use a pant-blow breathing pattern is a relaxation technique more suited for the earlier stages of labor, not the transition phase.
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Alaska Natives experience higher levels of violence, poverty, and drug and alcohol use, and fewer resources. How can the nurse help these patients?
- A. Tell the patient to stop using substances.
- B. Provide resources that are specific for this population.
- C. Tell the patient to call the police.
- D. Report the abuse to the social worker.
Correct Answer: B
Rationale: The correct answer is B because providing resources specific to Alaska Natives addresses the unique challenges they face. This can include culturally sensitive support services, mental health resources, and community programs. Choice A is incorrect as simply telling the patient to stop using substances is not addressing the underlying issues. Choice C is inappropriate as telling the patient to call the police may not be safe or effective in all situations. Choice D is also incorrect as reporting abuse to a social worker may be necessary but does not directly address the patient's immediate needs for support and resources.
The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicill in
- B. Azithro mycin
- C. Ceftriax one
- D. Acyclov ir
Correct Answer: A
Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.
Why was the Bradley Method originally introduced?
- A. as a novel approach to pregnancy where low-intervention, medication-free births were the goal
- B. as an education program that supported use of twilight birth
- C. as a system of supporting families wanting community birth
- D. as a program of education that focused on the importance of using a doula instead of a partner as a birth support
Correct Answer: A
Rationale: The correct answer is A: as a novel approach to pregnancy where low-intervention, medication-free births were the goal. The Bradley Method was introduced in the late 1940s by Dr. Robert Bradley with the aim of empowering women to have natural childbirth experiences without unnecessary medical interventions. This method promotes education and preparation for childbirth, emphasizing relaxation techniques, partner involvement, and natural pain management strategies. The other choices, B, C, and D, are incorrect because they do not align with the fundamental principles of the Bradley Method, which focuses on promoting low-intervention, medication-free births through education and empowerment of expectant parents.
The nurse is preparing a client for a scheduled cesarean delivery. What is the priority preoperative instruction?
- A. Eat a high-protein meal before surgery.
- B. Empty your bladder before the procedure.
- C. Avoid brushing your teeth on the morning of surgery.
- D. Refrain from taking prescribed medications.
Correct Answer: B
Rationale: The correct answer is B: Empty your bladder before the procedure. This is the priority preoperative instruction because a full bladder can increase the risk of complications during surgery, such as injury to the bladder or difficulties in catheter insertion. It is essential to ensure the bladder is empty to provide a clear surgical field and prevent urinary retention postoperatively.
Explanation for other choices:
A: Eating a high-protein meal before surgery is not recommended as it can increase the risk of aspiration during anesthesia.
C: Avoiding brushing teeth on the morning of surgery is not a priority instruction. Maintaining oral hygiene is important, but it does not directly impact the surgical procedure.
D: Refraining from taking prescribed medications should be discussed with the healthcare provider, as certain medications may need to be taken even on the day of surgery to prevent complications.