Nokea
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate variability
- D. Fetal heart rate of 118/min
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (tachysystole) can lead to fetal distress by reducing uteroplacental blood flow. Oxytocin should be discontinued if contractions become excessive. Moderate variability and normal fetal heart rate do not indicate distress.
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The nurse in labor and birth is caring for a Muslim patient during the active phase of labor. The nurse notes that the patient quickly draws away when touched. Which intervention should the nurse implement?
- A. Ask the charge nurse to reassign you to another patient.
- B. Assume that she does not like you and decrease your time with her.
- C. Continue to touch her as much as you need to while providing care.
- D. Limit touching to a minimum because physical contact may not be acceptable in her culture.
Correct Answer: D
Rationale: The appropriate intervention for the nurse to implement in this situation is to limit touching to a minimum because physical contact may not be acceptable in the patient's culture. In Islam, modesty and privacy are significant aspects of the faith, and physical contact, especially with someone of the opposite gender, may be considered inappropriate or uncomfortable for the patient. Respecting and acknowledging the patient's cultural background and preferences is essential in providing culturally competent care. Therefore, it is important for the nurse to be mindful of the patient's boundaries and minimize any unnecessary physical contact while still providing necessary care and support during labor.
A nurse is assessing the knowledge of new parents of a child born with Klinefelter syndrome. Which statement accurately describes this genetic disorder?
- A. Klinefelter syndrome is a sex chromosome abnormality.
- B. It affects only female children.
- C. The disorder is expressed as trisomy XYY.
- D. The child with this disorder will grow to be infertile.
Correct Answer: A
Rationale: Klinefelter syndrome, also known as trisomy XXY, is a sex chromosomal deviation that is expressed in males. Turner syndrome (monosomy X) is displayed in females. Most males with Klinefelter syndrome are tall, may be infertile, and are slow to learn; however, those who have mosaic Klinefelter syndrome may be fertile as adults.
A client at 24 weeks of gestation says she has a glass of wine with dinner every evening. Why should the nurse counsel her to eliminate all alcohol intake?
- A. Daily consumption of alcohol indicates a risk for alcoholism.
- B. She is at risk for abusing other substances as well.
- C. Alcohol places the fetus at risk for altered brain growth.
- D. Alcohol places the fetus at risk for multiple organ anomalies.
Correct Answer: C
Rationale: Alcohol consumption during pregnancy is associated with fetal mental retardation, learning disabilities, and other developmental issues.
A primipara patient asks about possible support options for her during the labor process. She is apprehensive that her family members will not be prepared to assist her during this time. Which option would be most effective for this patient?
- A. Reassure the patient that the labor and birth staff consists of highly trained nurses who are well educated to take care of laboring patients so that should be sufficient.
- B. Encourage the patient to take prepared childbirth classes with her husband because that should provide the best support by a family member.
- C. Provide information to the patient about obtaining a doula during the labor process.
- D. Tell the patient that this is a normal feeling based on fear of the unknown and that it will subside once she starts the labor process.
Correct Answer: C
Rationale: Providing information to the patient about obtaining a doula during the labor process is the most effective option in this scenario. A doula is a trained professional who provides physical, emotional, and informational support to the mother before, during, and after childbirth. They can help the mother feel supported and empowered during labor, especially if family members are unavailable or unprepared to offer the necessary support. Doulas can also help in communication with the medical staff, advocate for the mother's preferences, and provide comfort measures. Therefore, recommending the option of obtaining a doula would help address the patient's concerns about support during labor.
Which statement is the most complete and accurate description of medical abortions?
- A. Medical abortions are performed only for maternal health.
- B. They can be achieved through surgical procedures or with drugs.
- C. Medical abortions are mostly performed in the second trimester.
- D. They can be either elective or therapeutic.
Correct Answer: D
Rationale: Medical abortions can be either elective (the woman's choice) or therapeutic (for maternal or fetal health). They are typically performed in the first trimester using medication.