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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.
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A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
- A. Indirect Coombs test
- B. Liver enzymes
- C. Uric acid level
- D. Serum medication level
Correct Answer: D
Rationale: The correct answer is D: Serum medication level. Monitoring the serum medication level is crucial during tocolytic therapy with magnesium sulfate as it helps ensure the therapeutic range is maintained to prevent toxicity or inadequate effectiveness. Reviewing the indirect Coombs test (A) is not necessary for monitoring tocolytic therapy. Checking liver enzymes (B) and uric acid level (C) are not directly related to magnesium sulfate therapy for preterm labor. In summary, monitoring the serum medication level is essential for the safety and efficacy of magnesium sulfate therapy.
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup cooked broccoli. Broccoli is a good source of calcium, with approximately 43 mg per cup. This is important for pregnant women, especially those following a vegan diet, as they need to ensure adequate calcium intake for fetal development and bone health. Avocado (choice A), banana (choice B), and potato (choice C) are not significant sources of calcium compared to broccoli. Avocado and banana are low in calcium, while potatoes have even less. Thus, broccoli is the best option for the client to meet her calcium needs.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. This is an abnormal finding as typical contraction durations should be around 60-90 seconds. Prolonged contractions can lead to decreased fetal oxygenation and distress. Choice B is incorrect as contractions 2-3 minutes apart are within the normal range. Choice C is incorrect as absent early deceleration is a reassuring sign of fetal well-being. Choice D is incorrect as a fetal heart rate of 140/min is within the normal range of 110-160/min.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct Answer: A
Rationale: The correct answer is A, as it encourages the client to make decisions based on their preferences. By stating, "You can bathe and dress your baby if you’d like to," the nurse offers support and control to the client during a difficult time. This empowers the client to engage in meaningful rituals and take control of the situation.
Choice B is incorrect because it imposes guilt on the client by suggesting that not holding the baby will make letting go harder, which may not be the case for everyone. Choice C is incorrect as naming the baby should be a personal decision and not a directive from the nurse. Choice D is incorrect because it assumes the client's readiness for another baby, which may not be the case and can be insensitive.
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.