Nokea
The nurse is assessing a client in labor with ruptured membranes. What finding indicates the need for immediate intervention?
- A. Temperature of 100.6°F.
- B. Clear amniotic fluid.
- C. Green, foul-smelling fluid.
- D. Client reports contractions every 5 minutes.
Correct Answer: C
Rationale: The correct answer is C: Green, foul-smelling fluid. This indicates meconium-stained amniotic fluid, which can be a sign of fetal distress and possible meconium aspiration. Immediate intervention is needed to prevent potential complications for the baby.
A: Temperature of 100.6°F could indicate maternal infection but does not require immediate intervention unless other signs are present.
B: Clear amniotic fluid is a normal finding.
D: Contractions every 5 minutes may indicate active labor, but it is not an immediate concern unless coupled with other signs of distress.
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A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.
Who created the Mongan Method?
- A. physician
- B. midwife
- C. hypnotherapist
- D. organization
Correct Answer: C
Rationale: The correct answer is C: hypnotherapist. The Mongan Method was created by Marie Mongan, who is a hypnotherapist. She developed this method as a childbirth education program that incorporates hypnosis techniques to help women have a more positive and empowering birthing experience. The other choices are incorrect because a physician, midwife, or organization did not create the Mongan Method. Marie Mongan's background in hypnotherapy is the key factor in why choice C is the correct answer.
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
A nurse is caring for a patient who discloses they are experiencing family violence. What nursing action should the nurse take to support the patient and promote their safety?
- A. Provide a safe environment for the patient to further disclose their experience.
- B. Converse with the patient’s partner and ask why IPV is occurring in their home.
- C. Report the patient’s accusations to other members of the family.
- D. Propose a plan to leave the abuser today.
Correct Answer: A
Rationale: The correct answer is A: Provide a safe environment for the patient to further disclose their experience. This is the most appropriate action as it prioritizes the patient's safety and well-being. By creating a safe space, the nurse can encourage the patient to share more details about the violence they are experiencing. This can help the nurse assess the situation accurately and provide necessary support and resources.
Choices B, C, and D are incorrect:
B: Conversing with the patient's partner and asking why IPV is occurring is inappropriate as it may put the patient at further risk and breach confidentiality.
C: Reporting the patient's accusations to other family members could worsen the situation and further endanger the patient.
D: Proposing a plan to leave the abuser today may not be feasible or safe without proper assessment and planning.
The nurse is educating a client about postpartum warning signs. Which symptom requires immediate medical attention?
- A. Increased lochia after breastfeeding.
- B. Perineal discomfort on day 3 postpartum.
- C. Fever of 101°F and foul-smelling lochia.
- D. Mild fatigue and trouble sleeping.
Correct Answer: C
Rationale: The correct answer is C: Fever of 101°F and foul-smelling lochia. This combination indicates a possible infection like endometritis, which can be life-threatening if not promptly treated. Fever is a sign of systemic infection, and foul-smelling lochia suggests an infected uterus. Immediate medical attention is crucial to prevent complications.
A: Increased lochia after breastfeeding is common and not necessarily alarming unless it is excessive or accompanied by other symptoms.
B: Perineal discomfort on day 3 postpartum is expected due to the healing process and does not typically require immediate medical attention.
D: Mild fatigue and trouble sleeping are common postpartum symptoms but do not indicate a medical emergency unless they are severe or persistent.