Nokea
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitor oxygen saturation and administer pain medication.
- B. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
- C. Perform a sterile vaginal examination and assess breath sounds.
- D. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery. Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively. Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure. Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
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Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.
A client at ten weeks gestation tells the nurse that she has been having 'morning sickness.' The nurse advises the client to eat foods that are easy to digest and low in fat. Which is the rationale for the nurse's instruction?
- A. A low-fat diet increases peristalsis,which reduces the food volume in the stomach
- B. A low-fat diet is digested faster and leaves less in the stomach that can be vomited
- C. Easily digested foods provide a better balance of fluids and electrolytes, resulting in less nausea and vomiting
- D. Easily digested foods are less likely to cause relaxation of the cardiac sphincter, which causes regurgitation and vomiting
Correct Answer: B
Rationale: The correct answer is B: A low-fat diet is digested faster and leaves less in the stomach that can be vomited. During pregnancy, hormonal changes can lead to morning sickness. Eating foods that are low in fat helps reduce the workload on the digestive system, allowing for quicker digestion. This means there is less food remaining in the stomach that could potentially trigger vomiting. Therefore, advising the client to eat low-fat foods can help alleviate morning sickness symptoms.
A: Incorrect. While a low-fat diet may aid in digestion, it does not specifically increase peristalsis to reduce food volume in the stomach.
C: Incorrect. While easily digested foods can be beneficial, the primary focus in this scenario is on reducing fat intake for faster digestion.
D: Incorrect. The issue of cardiac sphincter relaxation and vomiting is not directly related to the advice given by the nurse.
In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?
- A. Supine with legs elevated
- B. Squatting
- C. Left side-lying
- D. High Fowler's
Correct Answer: C
Rationale: The correct answer is C, left side-lying position. This position promotes optimal blood flow to the placenta, enhancing oxygenation to the fetus. It also helps prevent compression of the vena cava, ensuring adequate circulation to the mother. Supine position with legs elevated (A) can compress the vena cava, reducing blood flow to the fetus. Squatting (B) may not improve oxygenation to the fetus and can be tiring for the laboring client. High Fowler's position (D) can impede blood flow to the placenta due to compression of abdominal vessels.
A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?
- A. What concerns are you having now?
- B. Tell me how you are feeling.
- C. Everything is going just fine.
- D. You seem a little nervous.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice A and B encourage the client to express their concerns and feelings, promoting therapeutic communication.
2. Choice D acknowledges the client's emotions, showing empathy and understanding.
3. Choice C dismisses the client's anxiety, invalidating their feelings, hindering communication.
Summary:
Choices A, B, and D promote open communication and empathy, while choice C ignores the client's anxiety, making it the incorrect choice.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.