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Which action by the nurse prevents infection in the labor and birth area?
- A. Keeping under pad and linen as dry as possible
- B. Performing vaginal exam q hour while client in active area
- C. Cleaning secretion from vaginal area using back to front
- D. Using clean technique for all procedures
Correct Answer: D
Rationale: Using clean technique for all procedures helps prevent infection in the labor and birth area. A clean technique involves maintaining cleanliness and limiting contamination during procedures. This includes proper hand hygiene, use of clean gloves, and ensuring that equipment and supplies are kept clean and sterile as needed. By adhering to clean techniques, the nurse reduces the risk of introducing harmful microorganisms into the labor and birth area, ultimately reducing the chances of infection for both the mother and baby. It is important for the nurse to practice proper infection control measures to provide a safe environment for labor and birth.
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The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.
A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
The patient asks the nurse when her Nexplanon can be inserted. How does the nurse respond?
- A. after the delivery of your placenta
- B. only during your period
- C. while you are in labor
- D. during the delivery
Correct Answer: A
Rationale: The nurse would respond with option A, "after the delivery of your placenta." Nexplanon is a hormonal contraceptive implant that is typically inserted in the upper arm subdermally. It is recommended to wait until after the delivery of the placenta to reduce the risk of causing any harm to the fetus during pregnancy or labor. Inserting Nexplanon during labor or delivery is not recommended due to the potential risks involved.
The nurse is assessing a client with suspected gestational hypertension. What finding supports this diagnosis?
- A. Blood pressure of 150/90 mmHg.
- B. Proteinuria of +2.
- C. Fetal heart rate of 140 beats/minute.
- D. Mild edema in the lower extremities.
Correct Answer: A
Rationale: Gestational hypertension is diagnosed with a blood pressure of 140/90 mmHg or higher without proteinuria.
A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.