Nokea
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
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A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
When a pregnant woman develops ptyalism, which guidance should the nurse provide?
- A. Chew gum or suck on lozenges between meals.
- B. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals.
- C. Take short walks to stimulate circulation in the legs and elevate the legs periodically.
- D. Use pillows to support the abdomen and back during sleep.
Correct Answer: A
Rationale: The correct answer is A: Chew gum or suck on lozenges between meals. Ptyalism is excessive saliva production during pregnancy. Chewing gum or sucking on lozenges can help manage excessive saliva by promoting swallowing and reducing the sensation of saliva accumulation. This guidance addresses the symptom directly. Choices B, C, and D do not specifically address ptyalism. B focuses on nutrition, C on circulation, and D on physical comfort, which are important aspects of pregnancy but not directly related to managing ptyalism.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
A 4-day-old breastfeeding neonate, whose birth weight was 2,678 grams, has lost 286 grams since its cesarean birth. Which of the following actions should the nurse take?
- A. Nothing, because this is an acceptable weight loss.
- B. Advise the mother to stop breastfeeding and give formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: A weight loss of up to 10% of birth weight in the first week is considered normal for breastfed neonates.
Which type of cutaneous stimulation involves massage of the abdomen?
- A. Imagery
- B. Effleurage
- C. Mental stimulation
- D. Thermal stimulation
Correct Answer: B
Rationale: The correct answer is B: Effleurage. Effleurage is a type of massage technique involving long, gentle strokes on the skin. Massaging the abdomen with effleurage can help improve circulation, relax muscles, and promote digestion. Imagery (A) is a technique involving mental visualization, not physical touch. Mental stimulation (C) refers to cognitive activities, not physical touch. Thermal stimulation (D) involves the application of temperature changes, not massage. Therefore, effleurage is the most suitable choice for massage of the abdomen.