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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 In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery.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.
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A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
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.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.