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A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?
- A. Encourage the mother to walk to facilitate labor progression.
- B. Administer oxytocin to augment labor.
- C. Prepare for cesarean section.
- D. Encourage relaxation techniques to manage pain.
Correct Answer: A
Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.
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What advice should be given to the owner of the dog in case of dog bite
- A. Give away the animal
- B. Impound the dog
- C. Kill the dog
- D. Feed well and observe
Correct Answer: D
Rationale: The correct advice to give to the owner of the dog in case of a dog bite is to feed the dog well and observe its behavior closely. It is not necessary to give away, impound, or kill the dog immediately after a bite incident. By feeding the dog well and observing its behavior, the owner can see if there are any underlying issues that may have caused the dog to bite. Additionally, observing the dog can help the owner determine if the dog has any health issues that need to be addressed. This approach allows the owner to make an informed decision about the dog's future while ensuring the safety of others.
Which of the following actions is a violation of a psychiatric patient's rights?
- A. Paranoid patient with delusions about his family is told that if he makes a will, it might not be valid.
- B. The nurse confiscated the cellphone from patient's room and tell him it is being locked in the vault.
- C. Staff members confiscated written letters done by patients addressed to local newspaper.
- D. Patient is paid minimum wage for helping in the hospital kitchen.
Correct Answer: C
Rationale: In this scenario, the action that violates a psychiatric patient's rights is option C, where staff members confiscated written letters done by patients addressed to the local newspaper. Patients have the right to communicate freely and express their thoughts and feelings through various means, such as letter-writing. Confiscating these letters is a violation of their rights to free expression and communication. It is essential to respect and uphold the rights of psychiatric patients, including their right to communicate with others.
A postpartum client who delivered vaginally expresses concern about feeling "heavy" in the perineal area. What education should the nurse provide to address this sensation?
- A. Encourage the client to perform Kegel exercises regularly.
- B. Recommend the use of perineal pads for additional support.
- C. Educate the client about the process of uterine involution.
- D. Suggest the use of a perineal support garment.
Correct Answer: A
Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.
The newly hired nurse asks for advice from the supervisor. supervisor notices that the newly hired nurse felt uneasy upon learning that the fetus is on breech presentation. Which of the following is the BEST RESPONSE by the supervisor?
- A. "I understand how you feel. Tell me more."
- B. Is this your first time to witness a breech presentation"
- C. Are you afraid to assist the case"
- D. "Don' t worry. There's always a first time"
Correct Answer: A
Rationale: The best response by the supervisor is to acknowledge the newly hired nurse's emotions by saying, "I understand how you feel. Tell me more." This response shows empathy and validates the nurse's feelings, creating a supportive environment for open communication. It allows the nurse to express their concerns and fears, leading to a constructive discussion and providing an opportunity for guidance and reassurance. This approach fosters a positive mentorship and learning experience for the newly hired nurse.
A nurse is caring for a patient who is experiencing conflicting emotions about a recent diagnosis. What therapeutic communication technique should the nurse use to help the patient explore their feelings?
- A. Offering advice on coping strategies
- B. Providing reassurance and false hope
- C. Reflecting the patient's feelings and expressions
- D. Redirecting the conversation to a different topic
Correct Answer: C
Rationale: Reflecting the patient's feelings and expressions is a therapeutic communication technique that involves mirroring back the patient's emotions and thoughts. By doing this, the nurse validates the patient's experiences and helps them explore their feelings further. This technique can enhance the patient's self-awareness and promote emotional expression, leading to a deeper understanding of their conflicting emotions. Offering advice (Option A) may not be as effective because the focus should be on helping the patient process their own emotions. Providing reassurance and false hope (Option B) can hinder the patient's emotional exploration and may lead to trust issues if the reality does not align with the false reassurance. Redirecting the conversation to a different topic (Option D) avoids addressing the patient's conflicting emotions, which is crucial for therapeutic communication and support.