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A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non-rebreather mask at 8 L/min
- D. Cover the umbilical cord with sterile saline saturated towel
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This step is crucial to prevent compression of the umbilical cord and maintain blood flow to the fetus, reducing the risk of fetal distress. It also helps in preventing infection and protecting the exposed cord.
Choice A: Initiating an infusion of IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord and ensure fetal well-being.
Choice B: Performing a vaginal examination could further worsen the situation by putting pressure on the umbilical cord, leading to decreased blood flow to the fetus.
Choice C: Administering oxygen is important in fetal distress, but covering the umbilical cord takes precedence in this case to prevent further complications.
In summary, covering the umbilical cord with a sterile saline-saturated towel is the correct action to protect the cord and maintain fetal perfusion.
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A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact isolation. This is because MRSA is primarily spread through direct physical contact with the infected individual or contaminated surfaces. By implementing contact precautions, the nurse can prevent the spread of MRSA to other patients and healthcare workers. Droplet precautions (choice A) are used for diseases spread through large respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small respiratory droplets that remain suspended in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks gestation is contact isolation.
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.
A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing any procedure that involves contact with bodily fluids or potentially infectious material, such as blood or bodily secretions. Umbilical cord care may involve cleaning the area, which can have potential exposure to bodily fluids. The other choices (A, B, C) do not involve direct contact with bodily fluids or infectious material, so gloves are not necessary for those procedures. It is important to maintain infection control practices to prevent the spread of infections in the healthcare setting.