Nokea
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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Which teaching is most critical for a mother with gestational diabetes?
- A. Encourage a high-protein diet
- B. Teach the importance of blood glucose monitoring
- C. Advise on the importance of physical activity
- D. Monitor for preterm labor signs
Correct Answer: B
Rationale: The correct answer is B because monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. By regularly monitoring blood glucose levels, the mother can adjust her diet and insulin intake accordingly to maintain optimal blood sugar levels. This helps in reducing the risk of adverse outcomes such as macrosomia and neonatal hypoglycemia.
Choice A is incorrect because while a balanced diet is important, focusing solely on high-protein intake may not address the specific needs of gestational diabetes management.
Choice C is also important for overall health, but blood glucose monitoring takes precedence in managing gestational diabetes.
Choice D is incorrect as monitoring for preterm labor signs is important in pregnancy but is not directly related to managing gestational diabetes.
A nurse is a prenatal clinic is completing a skin assessment for a pregnant client in the second trimester. Which clinical findings should the nurse expect (select all that apply)?
- A. Eczema
- B. Psoriasis C.Linea nigra
- C. Chloasma
- D. Striae gravidarum C, D, E
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. During the second trimester of pregnancy, hormonal changes can lead to the development of Linea nigra, a dark vertical line that appears on the abdomen. This is a common skin change in pregnant women.
Explanation:
1. Eczema (choice A) and Psoriasis (choice B) are chronic skin conditions that are not typically associated with pregnancy. These conditions are not expected findings during the second trimester.
2. Chloasma (choice C) is also known as the "mask of pregnancy" and presents as dark patches on the face. This is a common skin change during pregnancy, especially in the second trimester.
3. Striae gravidarum (choice D) are stretch marks that may develop on the abdomen, breasts, and thighs during pregnancy. While this is a common skin change in pregnancy, it is not one of the expected findings in the second trimester according to the question.
In summary, the correct
Which is a priority nursing intervention for a post-operative patient who has had an incomplete abortion?
- A. Insertion of IV line and fluid replacement
- B. Methergine IM (Clerie said this one to diminish bleeding, but Quizlet said bolded answer)
- C. Positioning client on left side
- D. Preop teaching for surgery
Correct Answer: A
Rationale: The correct answer is A: Insertion of IV line and fluid replacement. This is the priority nursing intervention for a post-operative patient with an incomplete abortion because fluid replacement is essential to address potential hypovolemia from bleeding. Ensuring adequate IV access allows for prompt administration of fluids and medications to stabilize the patient's condition. Choice B, Methergine IM, may help reduce bleeding but is not the immediate priority. Choice C, positioning the client on the left side, is not as urgent as fluid replacement. Choice D, preop teaching for surgery, is not relevant in this post-operative scenario.
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.
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.