Nokea
While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions?
- A. Provide for extreme modesty.
- B. Assign a male caregiver.
- C. Arrange for the husband/partner to participate in labor.
- D. Provide adequate pain control.
- E. Respect protective amulets.
Correct Answer: A,D,E
Rationale: Arab women are extremely modest, usually have a low pain tolerance, and wear protective amulets. Female caregivers are preferred, and the husband is present but not a participant.
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The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?
- A. By offering the patient warm fluids to drink
- B. By helping the patient to ambulate in the room
- C. By seating the patient upright in a straight-back chair
- D. By positioning the patient on her right side
Correct Answer: B
Rationale: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
What is the nurse's most informative response?
- A. When you feel increased fetal movement
- B. When contractions are 10 minutes apart
- C. When membranes have ruptured
- D. When abdominal or groin discomfort occurs
Correct Answer: C
Rationale: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action?
- A. Check the fundus for position and firmness.
- B. Report to the doctor immediately.
- C. Change the pads and chart the time.
- D. Time how long it takes to soak one pad.
Correct Answer: A
Rationale: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.
What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?
- A. At the beginning of a contraction, hold your breath and push for 10 seconds.'
- B. Take a deep breath and push between contractions.'
- C. Begin pushing when a contraction starts and continue for the duration of the contraction.'
- D. At the beginning of a contraction, take two deep breaths and push with the second exhalation.'
Correct Answer: D
Rationale: When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.