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A nurse is caring for a patient who discloses they are experiencing family violence. What nursing action should the nurse take to support the patient and promote their safety?
- A. Provide a safe environment for the patient to further disclose their experience.
- B. Converse with the patient’s partner and ask why IPV is occurring in their home.
- C. Report the patient’s accusations to other members of the family.
- D. Propose a plan to leave the abuser today.
Correct Answer: A
Rationale: The correct answer is A: Provide a safe environment for the patient to further disclose their experience. This is the most appropriate action as it prioritizes the patient's safety and well-being. By creating a safe space, the nurse can encourage the patient to share more details about the violence they are experiencing. This can help the nurse assess the situation accurately and provide necessary support and resources.
Choices B, C, and D are incorrect:
B: Conversing with the patient's partner and asking why IPV is occurring is inappropriate as it may put the patient at further risk and breach confidentiality.
C: Reporting the patient's accusations to other family members could worsen the situation and further endanger the patient.
D: Proposing a plan to leave the abuser today may not be feasible or safe without proper assessment and planning.
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A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Prepare for insertion of an intrauterine pressure catheter.
- D. Assist the client into the knee-chest position.
Correct Answer: D
Rationale: The correct answer is D: Assist the client into the knee-chest position. This position helps relieve pressure on the umbilical cord, preventing compression and potential harm to the fetus. By positioning the client in knee-chest, gravity can aid in moving the fetus off the cord. Administering oxytocin (choice A) is not appropriate as the priority is to relieve pressure on the cord. Applying oxygen (choice B) does not address the immediate risk posed by the cord prolapse. Insertion of an intrauterine pressure catheter (choice C) is not indicated when the priority is to alleviate cord compression.
The nurse is teaching a client about foods rich in folic acid during pregnancy. Which food should the nurse recommend?
- A. Citrus fruits.
- B. Lean meats.
- C. Dairy products.
- D. Whole grains.
Correct Answer: A
Rationale: The correct answer is A, citrus fruits. Folic acid is important for fetal development and helps prevent birth defects. Citrus fruits like oranges, grapefruits, and lemons are rich sources of folic acid. They provide the necessary nutrients for a healthy pregnancy. Lean meats (B) are good sources of protein but not specifically high in folic acid. Dairy products (C) are important for calcium but do not contain significant amounts of folic acid. Whole grains (D) are beneficial for fiber and nutrients, but they are not the best source of folic acid compared to citrus fruits.
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 during this procedure to prevent the spread of infection. The umbilical cord stump is a potential entry point for bacteria, so gloves are necessary to maintain asepsis.
A: Assisting a mother with breastfeeding does not require gloves as it is a clean procedure.
B: Performing a newborn's initial bath does not require gloves unless there are open wounds on the newborn.
C: Administering the measles, mumps, rubella vaccine may require gloves, but the primary concern is needlestick safety rather than infection control through glove use.
The nurse is assessing a client at 10 weeks' gestation with hyperemesis gravidarum. What is the priority nursing action?
- A. Encourage small, frequent meals.
- B. Monitor for signs of dehydration.
- C. Administer antiemetics as prescribed.
- D. Encourage fluid intake between meals.
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of dehydration. Dehydration is a serious complication of hyperemesis gravidarum and can lead to electrolyte imbalances and maternal-fetal complications. By monitoring for signs of dehydration, the nurse can intervene promptly to prevent further complications. Encouraging small, frequent meals (choice A) may help manage nausea but does not address the risk of dehydration. Administering antiemetics (choice C) may be necessary, but monitoring for dehydration takes precedence. Encouraging fluid intake between meals (choice D) is important, but assessing for dehydration is more critical in this situation.
The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.