Nokea
Which nursing intervention is an independent function of the professional nurse?
- A. Administering oral analgesics
- B. Requesting diagnostic studies
- C. Teaching the patient perineal care
- D. Providing wound care to a surgical incision
Correct Answer: C
Rationale: Teaching is an independent nursing function, whereas administering medications or requesting diagnostic studies are dependent functions requiring physician orders.
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Which is the most important reason for evaluating the pattern of weight gain in pregnancy?
- A. Prevents excessive adipose tissue deposits
- B. Determines cultural influences on the woman's diet
- C. Assesses the need to limit caloric intake in obese women
- D. Identifies potential nutritional problems or complications of pregnancy
Correct Answer: D
Rationale: The correct answer is D because evaluating the pattern of weight gain in pregnancy helps identify potential nutritional problems or complications. Monitoring weight gain can indicate if the woman is receiving adequate nutrition for fetal development, detect issues like gestational diabetes or pre-eclampsia, and ensure overall maternal and fetal health.
Incorrect choice analysis:
A: Preventing excessive adipose tissue deposits is important, but the primary reason for evaluating weight gain in pregnancy is to identify nutritional problems and complications.
B: Cultural influences on diet are relevant but not the most important reason for evaluating weight gain.
C: Limiting caloric intake in obese women is important, but evaluating weight gain is more about ensuring proper nutrition and detecting complications rather than focusing solely on caloric restriction.
A nurse is working with an active labor patient who is in preterm labor and has been designated as high risk. The patient is very apprehensive and asks the nurse, 'Is everything going to be all right?' The nurse replies, 'Yes, everything will be okay.' Following delivery via an emergency cesarean birth, the newborn undergoes resuscitation and does not survive. The patient is distraught over the outcome and blames the nurse for telling her that everything would be okay. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Fidelity
- C. Beneficence
- D. Accountability
Correct Answer: B
Rationale: Fidelity involves keeping promises and being truthful; the nurse violated this principle by making an unrealistic promise.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
- A. The client's readiness to learn
- B. The client's educational background
- C. The order in which the information is presented
- D. The extent to which the pregnancy was planned
Correct Answer: A
Rationale: When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be 'ready to learn' about ways to relieve morning sickness.
The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan?
- A. Insulin production is decreased during pregnancy
- B. Increase daily caloric intake is needed
- C. Injection requirements remain the same
- D. Blood sugars need less monitoring in the first trimester
Correct Answer: B
Rationale: An increase in caloric intake is often necessary to meet the increased metabolic demands of pregnancy, especially in clients with gestational diabetes.
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
- A. Discontinue the Pitocin infusion
- B. Medicate the client with an additional 1 mg of Stadol IV push
- C. Notify the healthcare provider
- D. Instruct the client to use deep breathing during contraction
Correct Answer: D
Rationale: Deep breathing techniques (D) can help manage pain without additional medication.