Nokea
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. This combination can lead to hemolytic disease in newborns due to Rh incompatibility. If the mother is Rh negative and the father is Rh positive, there is a chance that the fetus may inherit the Rh-positive factor from the father, causing the mother's immune system to produce antibodies against the Rh factor in subsequent pregnancies, potentially leading to hemolytic disease in newborns.
Incorrect choices:
A: The mother is Rh positive, and the father is Rh negative - This combination does not result in Rh incompatibility as the fetus will not inherit the Rh-negative factor from the father.
C: The mother and the father are both Rh positive - Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, so this choice is incorrect.
D: The mother and the father are both Rh negative - In this case, there is no Rh incompatibility present,
The nurse practicing in a labor setting knows the woman most at risk for a uterine rupture is:
- A. G4 who had all 4 c/s birth
- B. G5 who had 2 vaginal birth and 2 c/s births
- C. G2 low segment vertical incision for delivery of 10lb infant
- D. G3 who had 2 lower segment transverse c/s birth
Correct Answer: C
Rationale: The correct answer is C because a low segment vertical incision for delivery of a large infant (10lb) puts the woman at the highest risk for uterine rupture. This type of incision weakens the uterine wall, increasing the likelihood of rupture during subsequent pregnancies or labor. Choices A, B, and D involve lower segment transverse c-section births, which are less likely to result in uterine rupture compared to a vertical incision. Additionally, the number of previous births or the mode of delivery does not increase the risk of uterine rupture as much as the type of uterine incision.
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.
What does intimate partner violence refer to?
- A. violence that occurs in public spaces, such as streets or parks, between acquaintances or strangers
- B. violence or abuse that occurs within a relationship, involving physical assault, sexual violence, emotional or psychologic abuse, controlling behaviors, and economic abuse
- C. violence primarily directed toward children by their parents or guardians
- D. violence that is limited to verbal arguments and does not involve physical harm
Correct Answer: B
Rationale: The correct answer is B because intimate partner violence refers to violence or abuse that occurs within a relationship, involving various forms of abuse like physical assault, sexual violence, emotional or psychological abuse, controlling behaviors, and economic abuse. This definition specifically highlights the nature of violence within the context of intimate relationships, distinguishing it from violence that occurs in public spaces (choice A), violence directed toward children (choice C), or limited to verbal arguments without physical harm (choice D). Choice A is incorrect as it focuses on violence between acquaintances or strangers in public spaces. Choice C is incorrect as it refers to violence toward children. Choice D is incorrect as it excludes physical harm, which is often a significant aspect of intimate partner violence.