Nokea
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
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The nurse provides education regarding male sterilization. What important information is provided?
- A. “Many people have vasectomies reversed.â€
- B. “You will need to return to the office to check for sperm in your ejaculate.â€
- C. “You will be sterile after 3 months.â€
- D. “Vasectomy consent forms must have both partners’ consent.â€
Correct Answer: B
Rationale: The correct answer is B: "You will need to return to the office to check for sperm in your ejaculate." This information is crucial as it ensures the success of the sterilization procedure. By checking for sperm in the ejaculate, the effectiveness of the vasectomy can be confirmed. This step is important to ensure that the individual is indeed sterile and can rely on the procedure for contraception.
Choice A is incorrect because vasectomy reversal is not always successful and should not be assumed. Choice C is incorrect as sterility is not immediate and may take several months after the procedure. Choice D is incorrect as consent forms for vasectomy typically require only the individual undergoing the procedure to give consent.
In summary, choice B is correct because it emphasizes the need for follow-up to confirm sterility, while the other choices provide incorrect or irrelevant information regarding male sterilization.
The nurse is educating a client about gestational diabetes. What is the most important teaching point?
- A. Avoid all carbohydrates.
- B. Check your blood sugar only when symptomatic.
- C. Monitor blood sugar regularly as prescribed.
- D. Increase your physical activity significantly.
Correct Answer: C
Rationale: The correct answer is C: Monitor blood sugar regularly as prescribed. This is crucial in managing gestational diabetes to ensure blood sugar levels are within target range, preventing complications for both mother and baby. Regular monitoring helps track the effectiveness of treatment and dietary adjustments. Avoiding all carbohydrates (A) is not recommended as some are necessary for energy. Checking blood sugar only when symptomatic (B) is insufficient as it may miss important fluctuations. Increasing physical activity significantly (D) is beneficial but not the most important teaching point compared to consistent blood sugar monitoring.
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal.... Which of the following actions should the nurse take first?
- A. Change the client's position.
- B. Palpate the uterus to assess for tachysystole.
- C. Increase the client's IV infusion rate.
- D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Rationale: The correct answer is A: Change the client's position. Late decelerations indicate uteroplacental insufficiency, which can be caused by pressure on the vena cava from the uterus. Changing the client's position can alleviate this pressure, improving fetal oxygenation. Palpating the uterus or increasing IV infusion rate may not address the underlying issue. Administering oxygen is important but should come after addressing the positional issue to ensure optimal oxygen delivery to the fetus.
A patient is seen in the primary care clinic for a sinus infection and is prescribed antibiotics. The only other medication that this patient currently takes is an oral contraceptive. What is the most important education the nurse must give to the patient regarding her medications?
- A. If you have nausea with this combination of medication, make sure to take them with food.
- B. You must use a backup method for contraception while taking antibiotics.
- C. Oral contraceptives are contraindicated with many antibiotics.
- D. No education is necessary; these medications do not interact.
Correct Answer: B
Rationale: Step 1: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora.
Step 2: Failure to use a backup method can lead to unintended pregnancy.
Step 3: Therefore, it is crucial for the nurse to educate the patient on using a backup method to prevent pregnancy.
Summary: Choice A is incorrect as nausea is not the main concern. Choice C is incorrect as not all antibiotics interact with oral contraceptives. Choice D is incorrect as there is a potential interaction between antibiotics and oral contraceptives.