Nokea
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids such as saliva and urine. This is important for the nurses to understand as they care for both the mother and the newborn to prevent transmission.
Choice A is incorrect because acyclovir is not used to treat cytomegalovirus, but rather for other viral infections like herpes. Choice C is incorrect because lesions are not typically visible on the mother's genitalia with cytomegalovirus. Choice D is incorrect because airborne precautions are not necessary for cytomegalovirus transmission.
You may also like to solve these questions
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is important to prevent compression of the umbilical cord, which can lead to decreased blood flow to the fetus resulting in fetal distress or demise. By covering the protruding cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain adequate blood flow until further interventions can be performed by the healthcare team. Performing a vaginal examination by applying upward pressure on the presenting part (choice A) can further compress the cord and worsen the situation. Administering oxygen via nonrebreather mask (choice C) and initiating an infusion of IV fluids (choice D) are important interventions but should be done after addressing the umbilical cord protrusion to ensure adequate oxygenation and perfusion to the fetus.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" In the occipitoposterior position, the baby's head is pressing against the mother's back, causing intense back pain. Placing the client in a hands-and-knees position can help alleviate this discomfort by encouraging the baby to rotate into a more favorable position. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the intervention.
Incorrect choices:
A: "Does that lessen your suprapubic pain?" - This question is not directly related to the occipitoposterior position or the hands-and-knees intervention.
B: "Are you feeling relief from your pelvic pressure?" - While pelvic pressure may be present, the primary concern with the occipitoposterior position is back labor.
C: "Do your contractions feel further apart?" - Contractions may not necessarily change in frequency with a change in position, especially in cases of fetal malposition.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for a client taking digoxin during pregnancy. Digoxin has a narrow therapeutic range, and monitoring the serum level helps ensure the client is taking the medication as prescribed. Option A is not as reliable as self-reporting may not be accurate. Option B, assessing kidney function, is important but not directly related to medication adherence. Option C, determining the apical pulse rate, may indicate the medication's effectiveness but does not confirm adherence. Checking the serum medication level directly assesses the actual drug concentration in the body, providing concrete evidence of adherence.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus indicates proper involution of the uterus, a sign of potential improvement.
- Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition, indicating hypotension.
- Moderate lochia rubra is a normal finding in the postpartum period.
- Thready pulse is an indication of potential worsening condition, suggesting poor perfusion.
- Fundus firm to palpation is a normal finding indicating proper uterine contraction and involution.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce swelling, promote healing, and provide comfort for the client with a fourth-degree laceration. Warm compress can improve circulation and help with pain relief.
Choice B: Providing a cool sitz bath may not be ideal for promoting healing in this case as warmth is more beneficial.
Choice C: Administering methylergonovine is not appropriate for a perineal laceration and can cause unwanted side effects.
Choice D: Applying povidone-iodine after voiding can be irritating to the already sensitive area and may delay healing.