Nokea
What is the priority action for a mother with a fever during labor?
- A. Administer antipyretics
- B. Provide IV antibiotics
- C. Encourage hydration orally
- D. Notify the healthcare provider immediately
Correct Answer: B
Rationale: The correct answer is B: Provide IV antibiotics. Fever during labor could indicate infection, which can be harmful to both the mother and baby. Administering IV antibiotics is the priority action to treat the infection promptly and prevent complications. Administering antipyretics only treats the symptom, not the underlying cause. Encouraging hydration orally may be important but should not take precedence over addressing a potential infection. Notifying the healthcare provider is important, but immediate intervention with antibiotics is crucial in this situation.
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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.
Alaska Natives experience higher levels of violence, poverty, and drug and alcohol use, and fewer resources. How can the nurse help these patients?
- A. Tell the patient to stop using substances.
- B. Provide resources that are specific for this population.
- C. Tell the patient to call the police.
- D. Report the abuse to the social worker.
Correct Answer: B
Rationale: The correct answer is B because providing resources specific to Alaska Natives addresses the unique challenges they face. This can include culturally sensitive support services, mental health resources, and community programs. Choice A is incorrect as simply telling the patient to stop using substances is not addressing the underlying issues. Choice C is inappropriate as telling the patient to call the police may not be safe or effective in all situations. Choice D is also incorrect as reporting abuse to a social worker may be necessary but does not directly address the patient's immediate needs for support and resources.
The nurse is caring for a client in labor with ruptured membranes. What finding suggests umbilical cord prolapse?
- A. Clear amniotic fluid.
- B. Variable decelerations on the fetal monitor.
- C. Contractions every 2 minutes.
- D. Maternal blood pressure of 110/70 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Variable decelerations on the fetal monitor. This finding suggests umbilical cord prolapse because the cord can become compressed during contractions, leading to variable decelerations. It is a serious complication that requires immediate intervention to prevent fetal distress.
A: Clear amniotic fluid is a normal finding after rupture of membranes.
C: Contractions every 2 minutes may indicate tachysystole, but not specifically cord prolapse.
D: Maternal blood pressure is not directly related to cord prolapse.
The nurse is caring for a client at 34 weeks' gestation with suspected preterm labor. What is the priority nursing action?
- A. Administer corticosteroids as prescribed.
- B. Encourage ambulation to relieve contractions.
- C. Provide the client with a high-protein snack.
- D. Monitor maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Administer corticosteroids as prescribed. Administering corticosteroids helps accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. It is the priority action in suspected preterm labor at 34 weeks' gestation.
Explanation for why other choices are incorrect:
B: Encouraging ambulation may not be safe in preterm labor as it can increase the risk of delivering the baby prematurely.
C: Providing a high-protein snack is not the priority action in suspected preterm labor.
D: Monitoring maternal blood pressure is important, but not the priority in this situation where the focus is on preventing complications for the preterm infant.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select all that apply.
- A. Buttocks
- B. Neck
- C. Leg
- D. Arm
Correct Answer: B
Rationale: The correct answer is B: Neck. The patch contraception is most effective when applied to a clean, dry, and hairless area of the body. The neck is a suitable site because it is easily accessible, non-occlusive, and less likely to be affected by clothing friction. Placing the patch on the neck also helps avoid skin irritation and allows for optimal absorption of hormones.
Choice A: Buttocks - The buttocks may not be an ideal site as it can be covered by clothing and may not allow for proper adherence and absorption.
Choice C: Leg - The leg is not typically recommended as a site for the patch due to movement and friction from clothing that may affect patch adhesion and hormone absorption.
Choice D: Arm - While the arm is a possible site for the patch, it is not as ideal as the neck because it may be subject to more movement and rubbing against clothing, potentially affecting patch adherence and effectiveness.