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Which nursing intervention is written correctly?
- A. Force fluids as necessary.
- B. Observe interaction with the infant.
- C. Encourage turning, coughing, and deep breathing.
- D. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
Correct Answer: D
Rationale: Interventions must be detailed and specific; assisting to ambulate within specified timeframes is clear and actionable.
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A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
- A. Give the first dose of the vaccine for rotavirus if any have diarrhea now.
- B. Obtain signed consent from the mother for administration of hepatitis B vaccine
- C. Prepare the first dose for DTaP
- D. Ask the mother if she wants the infant immunized for
Correct Answer: B
Rationale: Hepatitis B vaccine is routinely given at birth, and consent is required (B).
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
- A. Provide oral hydration
- B. Have a complete blood count (CBC) drawn
- C. Obtain a specimen for urine analysis
- D. Place the client on strict bedrest
Correct Answer: C
Rationale: Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
In teaching a pregnant adolescent about nutrition, what should the nurse include in the care plan?
- A. Determine the weight gain needed to meet adolescent growth and add 35 lb.
- B. Suggest that she does not eat at fast food restaurants to avoid foods of poor nutritional value.
- C. Realize that most adolescents are unwilling to make dietary changes during pregnancy.
- D. Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium.
Correct Answer: A
Rationale: Rationale for Correct Answer A: The correct answer is A because it addresses the specific nutritional needs of a pregnant adolescent by considering her growth and weight gain requirements. It is essential to determine the appropriate weight gain based on the adolescent's pre-pregnancy weight and BMI to ensure a healthy pregnancy. Adding a standard amount (usually around 35 lb) on top of the recommended weight gain for adolescents accounts for the additional needs of the growing fetus.
Summary of Incorrect Choices:
B: This choice focuses on avoiding fast food restaurants but does not address the specific nutritional needs of a pregnant adolescent.
C: Assuming that most adolescents are unwilling to make dietary changes is a generalization and does not provide tailored guidance for the individual's needs.
D: While emphasizing the need to eliminate unhealthy snacks is important, it does not address the overall nutritional requirements and weight gain needed for a pregnant adolescent.
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client's 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.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicated that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record?
- A. 3-1-2-0-3
- B. 4-1-2-0-3
- C. 2-1-2-1-2
- D. 3-1-1-0-3
Correct Answer: D
Rationale: (D) describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children.