Nokea
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
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Which action is the most appropriate nursing measure when a baby has an unexpected defect at birth?
- A. Remove the baby from the delivery area immediately.
- B. Inform the parents immediately that something is wrong.
- C. Tell the parents that the baby has to go to the nursery immediately.
- D. Explain the defect and show the baby to the parents as soon as possible.
Correct Answer: D
Rationale: When a baby is born with an unexpected defect, it is crucial for the nursing staff to explain the defect to the parents and show the baby to them as soon as possible. This approach allows for open communication, transparency, and the opportunity for the parents to start processing the situation emotionally. By involving the parents and keeping them informed, trust and understanding can be established between the healthcare providers and the family, ultimately fostering a supportive environment for everyone involved in the care of the baby. It is essential to approach the situation with empathy and sensitivity while providing the necessary information to the parents.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
A patient asks the nurse about using the basal body temperature method as contraception. What statement made by the patient indicates that the patient needs further teaching?
- A. “I need to take my temperature before I even sit up in bed.â€
- B. “A rise of 0.4° F above my baseline temperatures for 3 days indicates it is safe to have condomless sex.â€
- C. “I need to use a special thermometer to take my basal body temperature.â€
- D. “I know I am about to ovulate when my temperature rises at least 0.4° F.â€
Correct Answer: B
Rationale: Option B is the statement made by the patient that indicates the need for further teaching. In the basal body temperature method of contraception, a sustained temperature rise typically indicates ovulation has already occurred, making it unsafe to have condomless sex. It is the drop in temperature just before ovulation that is used to predict a fertile window. Therefore, a rise in temperature would not indicate that it is safe to have condomless sex. The patient should be educated that the temperature shift indicates the end of the fertile window and that it is safest to avoid unprotected sex during the fertile window.
A patient receives an epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. The patient is at an increased risk of which problem during the fourth stage of labor?
- A. Bladder distention
- B. Postpartum hemorrhage
- C. Deep vein thrombosis (DVT)
- D. Infection
Correct Answer: A
Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.