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.
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A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Pull the pinna of the infant's ear forward before inserting the probe.
- B. Place the tip of the thermometer under the center of the infant's axilla
- C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
- D. Insert the oral thermometer in front of the infant's tongue.
Correct Answer: B
Rationale: Axillary temperature measurement is safe and non-invasive for infants.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: The correct answer is C: Tell the client they will start medication for HIV immediately after delivery. This is because starting HIV medication immediately after delivery helps prevent vertical transmission of the virus to the baby. Administering penicillin G (choice A) is not indicated for HIV treatment. Instructing the client to schedule an annual pelvic examination (choice B) is important but not the priority in this case. Reporting the client's condition to the local health department (choice D) may be necessary for public health surveillance, but it is not the immediate action required for the client's care in this situation.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is appropriate because the occipitoposterior position often leads to back labor due to the baby's position pressing on the mother's spine. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve pressure on the mother's back.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is more effective for back pain relief, not suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for addressing back pain, not pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect as the position change is unlikely to affect the timing of contractions significantly.
In summary, the correct question (Choice D) directly addresses the main issue associated with occipitoposterior
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
- A. Have the client's child translate.
- B. Ask a nursing student who speaks the same language as the client to translate.
- C. Request a female interpreter through the facility
- D. Allow the client's partner to translate.
Correct Answer: C
Rationale: Requesting a female interpreter through the facility ensures accurate and professional communication, respecting the client's privacy and cultural preferences. Using a child or partner to translate is inappropriate and may lead to misunderstandings.
Which of the following hormones is responsible for inducing ovulation?
- A. Estrogen
- B. Progesterone
- C. Follicle-stimulating hormone (FSH)
- D. Luteinizing hormone (LH)
Correct Answer: D
Rationale: The correct answer is D: Luteinizing hormone (LH). LH surge triggers ovulation by stimulating the release of the mature egg from the ovarian follicle. Estrogen and progesterone play roles in the menstrual cycle but do not directly induce ovulation. FSH is involved in follicular development but not ovulation.