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The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
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A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.
A client at 10 weeks' gestation reports frequent nausea. What dietary recommendation should the nurse provide?
- A. Avoid eating salty snacks.
- B. Drink fluids between meals.
- C. Consume three large meals a day.
- D. Avoid eating protein-rich foods.
Correct Answer: B
Rationale: The correct answer is B: Drink fluids between meals. This recommendation helps manage nausea during pregnancy by preventing dehydration, which can worsen symptoms. Consuming fluids between meals also helps maintain hydration and prevents an empty stomach, which can trigger nausea. A: Avoiding salty snacks is not directly related to managing nausea. C: Consuming three large meals a day may worsen nausea due to overeating. D: Avoiding protein-rich foods is not recommended as they are important for fetal development and overall nutrition during pregnancy.
The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.
What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.