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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 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.
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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
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.
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.
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.
A client in her third trimester complains of Braxton
- A. Report any stools that appear to have milk Hicks contractions. Which of the following interven- curds immediately to the infant's health care tions would help with this type of pain? Select all that provider. apply.
- B. Stools will change from green to yellowish brown
- C. Drink four to six glasses of water per day. to golden yellow over the next several days.
- D. Rest until the contractions subside.
Correct Answer: D
Rationale: The correct answer is D: Rest until the contractions subside. During Braxton Hicks contractions, rest can help alleviate the discomfort. It allows the body to relax and reduces the intensity of the contractions. Other options are incorrect because:
A: Reporting stools with milk curds to the infant's healthcare provider is unrelated to Braxton Hicks contractions.
B: Stool color changes are irrelevant to managing Braxton Hicks contractions.
C: Drinking water is important for overall health during pregnancy but does not directly address Braxton Hicks contractions.