Nokea
The nurse in labor and birth is caring for a Muslim patient during the active phase of labor. The nurse notes that the patient quickly draws away when touched. Which intervention should the nurse implement?
- A. Ask the charge nurse to reassign you to another patient.
- B. Assume that she does not like you and decrease your time with her.
- C. Continue to touch her as much as you need to while providing care.
- D. Limit touching to a minimum because physical contact may not be acceptable in her culture.
Correct Answer: D
Rationale: The appropriate intervention for the nurse to implement in this situation is to limit touching to a minimum because physical contact may not be acceptable in the patient's culture. In Islam, modesty and privacy are significant aspects of the faith, and physical contact, especially with someone of the opposite gender, may be considered inappropriate or uncomfortable for the patient. Respecting and acknowledging the patient's cultural background and preferences is essential in providing culturally competent care. Therefore, it is important for the nurse to be mindful of the patient's boundaries and minimize any unnecessary physical contact while still providing necessary care and support during labor.
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Which statement regarding the Family Systems Theory is inaccurate?
- A. Family system is part of a larger suprasystem.
- B. Family, as a whole, is equal to the sum of the individual members.
- C. Family roles are flexible.
- D. The family functions as a whole and adapts to changes.
Correct Answer: B
Rationale: Family Systems Theory posits that the family is greater than the sum of its parts, meaning the family unit's dynamics are not just the sum of individual members. The theory emphasizes family roles and adaptability within the system.
With regard to an obstetric litigation case, a nurse working in labor and birth is found to be negligent. Which intervention performed by the nurse indicates that a breach of duty has occurred?
- A. The nurse did not document fetal heart tones (FHR) during the second stage of labor.
- B. The patient was only provided ice chips during the labor period, which lasted 8 hours.
- C. The nurse allowed the patient to use the bathroom rather than a bedpan during the first stage of labor.
- D. The nurse asked family members to leave the room when she prepared to do a pelvic exam on the patient.
Correct Answer: A
Rationale: In an obstetric setting, failure to document fetal heart tones (FHR) during the second stage of labor is a critical breach of duty by the nurse. Monitoring FHR is essential to assess fetal well-being and detect any signs of distress or complications during labor. Neglecting to document this important vital sign could result in delayed recognition of fetal distress, potentially leading to adverse outcomes for the baby and the mother. Therefore, this intervention indicates negligence on the part of the nurse in this scenario.
To ensure client safety, the practicing nurse must have knowledge of The Joint Commission's current 'Do Not Use' list of abbreviations. Which term is acceptable for use regarding medication administration?
- A. q.o.or Q.O.D.
- B. MSO4 or MgSO4
- C. International Unit
- D. Lack of a leading zero
Correct Answer: C
Rationale: I.U.' and i.u.' are no longer acceptable because they could be misreaThe leading zero should be used before a decimal point.
A client at 24 weeks of gestation says she has a glass of wine with dinner every evening. Why should the nurse counsel her to eliminate all alcohol intake?
- A. Daily consumption of alcohol indicates a risk for alcoholism.
- B. She is at risk for abusing other substances as well.
- C. Alcohol places the fetus at risk for altered brain growth.
- D. Alcohol places the fetus at risk for multiple organ anomalies.
Correct Answer: C
Rationale: Alcohol consumption during pregnancy is associated with fetal mental retardation, learning disabilities, and other developmental issues.
The nurse is providing care to a patient who was just admitted to the labor and birth unit in active labor at term. The patient informed the nurse, “I have not received any prenatal care because I cannot afford to go to the doctor. And, this is my third baby, so I know what to expect.” What is the nurse’s primary concern when developing the patient’s plan of care?
- A. Low birth weight
- B. Oligohydramnios
- C. Gestational diabetes
- D. Gestational hypertension
Correct Answer: A
Rationale: The nurse's primary concern when developing the plan of care for a patient who has not received prenatal care and is now in active labor is the risk of low birth weight for the baby. Prenatal care plays a crucial role in monitoring the health of the pregnant woman and her baby, ensuring appropriate growth and development, and identifying any potential issues early on. Without prenatal care, important factors such as maternal nutritional status, appropriate weight gain, screening for conditions that can affect the baby's growth, and management of any complications during pregnancy may not have been addressed. As a result, the baby is at increased risk for being born with a low birth weight, which can lead to various health problems and complications both immediately after birth and in the long term. Therefore, the nurse should prioritize monitoring and addressing the risk of low birth weight in this situation.