Nokea
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
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A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
- A. Cleanse the tip of the penis in a side to side motion
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Perform the cleansing procedure with a fresh swab two times
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps straighten the urethra, allowing for easier insertion of the catheter. Lifting the penis also reduces the risk of trauma or injury during the procedure. Cleaning the tip of the penis in a side-to-side motion (choice A) can introduce bacteria into the urethra. Picking up the catheter 13 cm (5 in) from its tip (choice B) may contaminate the sterile end. Performing the cleansing procedure with a fresh swab two times (choice C) is not necessary and may increase the risk of irritation to the client's skin.
Which statement indicates understanding of the teaching?
- A. A transcutaneous electrical nerve stimulator will help with pelvic pressure
- B. I can use my ultrasound picture as a focal point during contractions
- C. Breathing techniques can help me stay relaxed during contractions
- D. Changing positions frequently can reduce my discomfort
- E. A warm shower or bath may help ease my labor pain
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of the teaching on coping strategies during labor. Breathing techniques are commonly taught to help manage pain and promote relaxation during contractions. This choice aligns with established labor preparation methods. Other choices lack direct relevance to labor pain management. A focuses on a specific device rather than coping mechanisms. B focuses on a visual aid, which may not address pain management directly. D mentions changing positions, which is beneficial but not as directly related to relaxation techniques. E mentions a warm shower or bath, which can help with pain relief but doesn't specifically address relaxation techniques for coping with contractions.
Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
- A. evaluating the fetal heart rate tracing
- B. monitoring urine output
- C. Checking the client's blood pressure
- D. administering labetalol
- E. Starting the continuous IV infusion
- F. inserting an indwelling urinary catheter
Correct Answer: C,D
Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.