Nokea
A woman in active labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing action?
- A. Elevate the mother's hips to relieve pressure on the cord.
- B. Prepare for immediate cesarean section.
- C. Administer intravenous fluids rapidly.
- D. Perform a vaginal examination to assess cervical dilation.
Correct Answer: B
Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.
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A woman in active labor requests hydrotherapy for pain relief. What is the nurse's priority action before initiating hydrotherapy?
- A. Obtain informed consent from the mother.
- B. Ensure that the labor room is equipped with a hydrotherapy tub.
- C. Assess the maternal and fetal conditions for eligibility.
- D. Review the mother's medical history for contraindications.
Correct Answer: C
Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.
A patient with chronic kidney disease is prescribed calcium carbonate as a phosphate binder. Which instruction should the nurse provide to the patient regarding calcium carbonate administration?
- A. Take with meals
- B. Take on an empty stomach
- C. Take with a full glass of water
- D. Crush tablets before administration
Correct Answer: A
Rationale: Calcium carbonate should be taken with meals because it requires the presence of stomach acid to be properly absorbed. Taking it with meals helps ensure optimal absorption and effectiveness as a phosphate binder in patients with chronic kidney disease. Administering calcium carbonate on an empty stomach may lead to gastrointestinal side effects such as upset stomach, bloating, and constipation. Taking it with a full glass of water is also recommended to help prevent potential gastrointestinal issues and to ensure proper hydration. Crushing tablets before administration is not advised unless specifically instructed by a healthcare provider, as it can alter the drug's release and absorption properties.
In planning for Sonny's oxygen therapy, the nurse should consider which of the following, EXCEPT
- A. need for a humidifier.
- B. length of tubing .
- C. determine the age of Excel.
- D. manner of administering oxygen, continuous or intermittent.
Correct Answer: C
Rationale: The nurse does not need to determine the age of Excel when planning for Sonny's oxygen therapy. This information is irrelevant to the specific care requirements of Sonny's oxygen therapy. Sonny's age, medical history, respiratory status, and oxygen needs are the key considerations in planning for his oxygen therapy. The nurse should focus on factors such as the need for a humidifier, length of tubing, and the manner of administering oxygen (continuous or intermittent) to ensure effective and safe delivery of oxygen therapy to Sonny.
Pulmonary Rehabilitation for COPD has a duration of at least 4 to 12 weeks. Which of the following should be avoided while patient is having this program?
- A. Pursed lip breathing
- B. Smoking cessation
- C. Aerobic, upper and lower body conditioning
- D. Peripheral muscle wasting
Correct Answer: B
Rationale: During pulmonary rehabilitation for COPD, smoking cessation should not be avoided but instead strongly encouraged. Smoking cessation is a crucial component in managing COPD and improving lung function. Continued smoking can exacerbate COPD symptoms and hinder the progress made through rehabilitation efforts. Therefore, it is essential for patients to quit smoking while undergoing pulmonary rehabilitation to maximize the benefits of the program and improve their overall lung health.
Which of the following charting rules will keep the nurse legally safe? I. Documenting worries and all concerns as verbalized by the patient. II Charting at the end of the shift only. III.Discussing of recorded cases and diagnosis of the patient. IV. Recording all information verbalized by patient and family.
- A. III, IV
- B. I
- C. I, III
- D. II
Correct Answer: B
Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.