Nokea
The nurse is preparing a client for a scheduled cesarean delivery. What is the priority preoperative instruction?
- A. Eat a high-protein meal before surgery.
- B. Empty your bladder before the procedure.
- C. Avoid brushing your teeth on the morning of surgery.
- D. Refrain from taking prescribed medications.
Correct Answer: B
Rationale: The correct answer is B: Empty your bladder before the procedure. This is the priority preoperative instruction because a full bladder can increase the risk of complications during surgery, such as injury to the bladder or difficulties in catheter insertion. It is essential to ensure the bladder is empty to provide a clear surgical field and prevent urinary retention postoperatively.
Explanation for other choices:
A: Eating a high-protein meal before surgery is not recommended as it can increase the risk of aspiration during anesthesia.
C: Avoiding brushing teeth on the morning of surgery is not a priority instruction. Maintaining oral hygiene is important, but it does not directly impact the surgical procedure.
D: Refraining from taking prescribed medications should be discussed with the healthcare provider, as certain medications may need to be taken even on the day of surgery to prevent complications.
You may also like to solve these questions
A 28-year-old primigravida admitted to antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?
- A. Assess for dehydration and starvation
- B. Isolated from family
- C. This condition is caused by psychogenic factor
- D. Similar to morning sickness
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Assessing for dehydration and starvation is crucial in managing hyperemesis gravidarum, as it can lead to serious complications for both the mother and the fetus. Dehydration can result from persistent vomiting and may require intravenous fluids. Starvation can occur due to poor nutrient intake. Monitoring these factors helps in providing appropriate treatment and preventing further health issues.
Summary of Incorrect Choices:
B: Isolating the patient from family is not necessary and can have negative psychological impacts. Support from family is crucial in managing hyperemesis gravidarum.
C: Hyperemesis gravidarum is a physical condition related to pregnancy, not a psychogenic factor.
D: Hyperemesis gravidarum is more severe and persistent than morning sickness, requiring different management strategies.
The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
What is the term for integrating a person's cultural beliefs into their health care?
- A. cultural integrity
- B. culturally responsive care
- C. holistic care
- D. integrative care
Correct Answer: B
Rationale: The correct answer is B: culturally responsive care. This term specifically refers to integrating a person's cultural beliefs into their health care. Culturally responsive care acknowledges and respects the diversity of beliefs and practices among patients. The other choices are incorrect because:
A: cultural integrity does not specifically address the integration of cultural beliefs in health care.
C: holistic care focuses on treating the whole person but does not specifically address cultural beliefs.
D: integrative care typically refers to combining conventional and complementary approaches to health care, not necessarily cultural beliefs integration.
Which assessment finding indicates uterine rupture?
- A. Contractions abruptly stop during labor
- B. Decreased maternal heart rate
- C. Gradual onset of mild pain during contractions
- D. Uterus becomes firm between contractions
Correct Answer: A
Rationale: The correct answer is A: Contractions abruptly stop during labor. Uterine rupture is a serious obstetric emergency where the integrity of the uterus is compromised, leading to potential life-threatening complications for both the mother and the fetus. When the uterus ruptures, contractions may abruptly stop due to the loss of muscle tone and coordination. This sudden cessation of contractions is a red flag indicating uterine rupture.
Choice B, decreased maternal heart rate, is not typically associated with uterine rupture. Choice C, gradual onset of mild pain during contractions, is more indicative of a normal labor process rather than uterine rupture. Choice D, uterus becomes firm between contractions, is not a specific sign of uterine rupture as it can occur in normal labor as well.