Nokea
A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?
- 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: D
Rationale: Pant-blow breathing helps prevent pushing before full cervical dilation and reduces pain.
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A charge nurse is working on a postpartum unit and discovers that one of the patients did not receive AM care during her shift assessment. The charge nurse questions the nurse assigned to provide care and finds out that the nurse thought “the patient should just do it by herself because she will have to do this at home.” On further questioning of the nurse, it is determined that the rest of her assigned patients were provided AM care. The assigned nurse has violated which ethical principle?
- A. Justice
- B. Truth
- C. Confidentiality
- D. Autonomy
Correct Answer: A
Rationale: Justice in healthcare ethics refers to the fair and equal distribution of resources, care, and treatment. In this scenario, the nurse's decision to not provide AM care to the specific patient, while providing care to other patients, violates the principle of justice. It is unfair and unjust to selectively provide care based on personal assumptions rather than patients' needs. All patients should be treated equally and receive appropriate care regardless of individual beliefs or assumptions.
The nurse is providing care to the adult female patient who presents to the emergency department with a suspected myocardial infarction (MI). Which symptom indicates a possible MI for the female patient?
- A. Chest pain that radiates to the right arm and jaw
- B. Episodic nausea/indigestion and palpitations
- C. Sudden onset of trouble walking, and loss of balance
- D. Swelling of the feet and shortness of breath
Correct Answer: B
Rationale: For female patients, the classic symptom of a myocardial infarction (MI) is often different from that in male patients. While chest pain that radiates to the right arm and jaw is a common symptom in male patients, female patients may present with more subtle symptoms. Episodic nausea/indigestion and palpitations are more commonly seen in female patients experiencing a myocardial infarction. It is important for healthcare providers to recognize and consider these atypical symptoms in female patients to ensure timely diagnosis and treatment.
Many communities now offer the availability of free-standing birth centers to provide care for low-risk women during pregnancy, birth, and postpartum. When counseling the newly pregnant patient regarding this option, the nurse should be aware that this type of care setting includes which advantages? (Select all that apply.)
- A. Staffing by lay midwives
- B. Equipped for obstetric emergencies
- C. Less expensive than acute care hospitals
- D. Safe, homelike births in a familiar setting
Correct Answer: B
Rationale: B. Equipped for obstetric emergencies: Free-standing birth centers are equipped to handle any obstetric emergencies that may arise during labor and birth. They have the necessary equipment and trained staff to respond quickly and effectively to emergencies to ensure the safety of both the mother and baby.
Which nursing intervention does not apply to a diagnosis of 'Deficient knowledge' related to conception?
- A. Assess the current level of factors promoting conception.'
- B. Provide information regarding conception in a supportive manner.'
- C. Evaluate the couple's support system.'
- D. Identify and describe the basic infertility tests.'
Correct Answer: C
Rationale: Evaluating the support system is more appropriate for a diagnosis related to ineffective coping rather than knowledge deficits.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure leads to decreased estrogen production and lack of ovulation, significantly affecting fertility.