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What is the recommended method of pain relief during labor for a woman who wants to avoid medication?
- A. Breathing techniques
- B. Massage
- C. Water immersion
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Breathing techniques help manage pain by promoting relaxation and reducing stress. Massage can provide comfort and help relieve muscle tension. Water immersion, such as a warm bath or shower, can ease contractions and promote relaxation. Choosing all options provides a comprehensive approach to pain relief during labor without medication. Options A, B, and C individually offer effective non-pharmacological methods, but using them in combination (D) offers a more holistic and effective pain management strategy.
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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can wait until after FHR monitoring. Assessing the fluid (B) may be important but not as urgent as monitoring the FHR.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available in case the client shows signs of toxicity, such as respiratory depression or loss of deep tendon reflexes.
What is the recommended method of pain relief during labor for a woman who wants to avoid medication and wants to move around freely?
- A. Nitrous oxide
- B. Intramuscular opioids
- C. Transcutaneous electrical nerve stimulation (TENS)
- D. All of the above
Correct Answer: A
Rationale: Nitrous oxide is a non-invasive pain relief option that allows the woman to move freely during labor.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning during the first trimester as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and the fetus. The nurse should report this finding to the provider for further evaluation and intervention.
Incorrect choices:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for concern at 10 weeks of gestation.
C: Nosebleeds are common in pregnancy due to increased blood volume and hormonal changes and are usually not serious unless severe or frequent.
D: Increased vaginal discharge is a normal pregnancy symptom caused by hormonal changes and increased blood flow to the pelvic area.
The nurse is preparing the infant for phototherapy.For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.
- A. Supplement feeding with sterile water.
- B. Dress in only a diaper.
- C. Cover newborn's eyes with a shield
- D. Apply lotion to skin every 4 Mr.
- E. Breastfeed every 2 to 3 hr.
Correct Answer:
Rationale: Increase IV fluids for better circulation