Which nursing intervention is an independent function of the professional nurse?
Rationale:
Teaching the patient perineal care is an independent function of the professional nurse. This intervention involves imparting knowledge and skills, which nurses are authorized to perform without direct physician orders, promoting patient autonomy and self-care. It reflects the nurse’s role in education, prevention, and health promotion, distinguishing it from actions requiring medical prescriptions or direct physician involvement.
A: Administering oral analgesics requires a physician’s order, making it a dependent nursing function rather than an independent one. Nurses follow prescriptions rather than initiate this intervention autonomously.
B: Requesting diagnostic studies falls under the physician’s authority; nurses cannot order tests independently, so this action is not within the nurse’s autonomous scope of practice.
D: Providing wound care to a surgical incision often requires a physician’s directive or protocol adherence, categorizing it as a dependent nursing task instead of an independent function.
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
Rationale:
The nurse should first obtain a blood glucose level. Measuring the infant’s blood glucose is essential to confirm hypoglycemia, which is common in LGA infants of diabetic mothers and causes jitteriness. This immediate assessment guides timely treatment to prevent complications. Identifying glucose levels prioritizes accurate diagnosis before interventions like feeding or environmental adjustments occur, ensuring patient safety.
A: Administer oxygen Oxygen is not the primary concern for jitteriness in LGA infants; this symptom typically indicates hypoglycemia, not respiratory distress, so oxygen administration is premature without confirming glucose status.
B: Feed the infant glucose water (10%) Feeding glucose without verifying blood sugar might mask symptoms or delay accurate diagnosis; initial confirmation of hypoglycemia is critical before initiating treatment to avoid inappropriate care.
D: Decrease environment stimuli Lowering stimuli may calm the infant, but it does not address the underlying cause of jitteriness, which is likely hypoglycemia; thus, it is not the first priority action.
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
Rationale:
Oxytocin should be immediately discontinued if contractions last 100 seconds because prolonged contractions can lead to uterine hyperstimulation, reducing placental blood flow and causing fetal distress. This duration exceeds safe limits, risking uterine rupture and fetal hypoxia, necessitating prompt cessation of the medication to protect both mother and baby during labor.
A: Uterus soft indicates no contraction intensity issues and does not mandate stopping oxytocin, as uterine tone is not compromised.
C: Four contractions in 10 minutes represent tachysystole, but the focus is on contraction duration, making this less critical than prolonged contractions.
D: Early deceleration of fetal heart rate reflects normal head compression, not fetal distress, so it doesn’t require immediate oxytocin discontinuation.
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?
Rationale:
The nurse violated the ethical principle of fidelity. Fidelity involves being truthful, keeping promises, and maintaining trust in the nurse-patient relationship. By assuring the patient that everything would be okay despite the uncertain outcome, the nurse gave false reassurance, breaching trust and failing to uphold honest communication which is essential in high-risk clinical situations.
A: Autonomy relates to respecting patients' rights to make informed decisions. This scenario focuses on truthfulness and trust, not the patient’s decision-making ability or independence.
C: Beneficence involves acting in the patient’s best interest to promote good. The issue here is honesty and trust, not the nurse’s intention to do good.
D: Accountability means accepting responsibility for actions. The dilemma centers on truthful communication, not the nurse’s ownership of outcomes or errors.
A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
Rationale:
A patient losing 30 lb during the 6-week postpartum period is concerning and warrants further evaluation. Rapid weight loss postdelivery can indicate inadequate nutrition, dehydration, or other health complications that may affect recovery and breastfeeding, necessitating careful assessment by healthcare providers to ensure both maternal and infant well-being during this critical phase.
B: Eating healthy and limiting processed foods supports nutritional recovery and weight management postpartum, indicating positive lifestyle choices rather than any cause for concern at the 6-week checkup.
C: Increased fruit and vegetable consumption enhances nutrient intake and promotes health during postpartum recovery, reflecting beneficial dietary habits rather than a problematic assessment factor.
D: Resuming usual exercise like walking 10 minutes nightly encourages gradual physical activity and supports postpartum health, representing a safe and appropriate behavior, not a concern at this stage.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 6 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
Rationale:
The nurse should monitor the fetal heart rate pattern. Monitoring fetal heart rate after spontaneous rupture of membranes is crucial to detect any signs of fetal distress or cord prolapse promptly, ensuring immediate intervention if needed. Clear fluid indicates no infection, but continuous monitoring safeguards fetal well-being during active labor progression at 6 cm dilation and 0 station.
B: Perform a vaginal examination is unnecessary immediately after rupture because assessing fetal descent and dilation is already established at 6 cm and 0 station, minimizing infection risk.
C: Encourage the client to ambulate is inappropriate at 6 cm dilation with ruptured membranes, as mobility could increase risk of cord prolapse or disrupt labor progression.
D: Administer pain medication is premature without assessing pain level or labor progression; priority remains fetal monitoring to ensure safety after membrane rupture.
In order to increase the absorption of iron by a pregnant patient, which beverage should an iron preparation be given with?
Rationale:
Iron preparations should be given with orange juice to increase absorption. Orange juice contains vitamin C, which enhances non-heme iron absorption by reducing ferric iron to ferrous iron in the gastrointestinal tract. This acidic environment prevents the formation of insoluble iron compounds, facilitating better uptake in the intestines, especially important during pregnancy when iron needs are elevated for fetal development and maternal health.
A: Tea contains tannins that bind iron, forming insoluble complexes that significantly reduce iron absorption, making it unsuitable to enhance iron uptake during pregnancy.
B: Milk is rich in calcium, which competes with iron for absorption sites, thereby inhibiting iron uptake and diminishing the effectiveness of iron supplementation.
C: Coffee has polyphenols that chelate iron, decreasing its bioavailability and impairing the absorption process, which is detrimental when trying to maximize iron intake.
A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?
Rationale:
The nurse should have the client transported to the hospital. Immediate hospital transfer is crucial due to the risk of severe hemorrhage from placenta previa, especially with third-trimester bleeding and no prenatal care. Hospitalization allows for close monitoring, potential blood transfusions, and emergency interventions to ensure maternal and fetal safety during this high-risk situation.
A: Schedule weekly prenatal appointments delays urgent care needed for active bleeding and potential complications, insufficient for immediate hemorrhage management in placenta previa during late pregnancy.
B: Contact social services for a temporary shelter does not address the urgent medical emergency requiring immediate assessment and intervention for vaginal bleeding and placental issues.
C: Obtain a hemoglobin and hematocrit level is important but secondary to urgent transport; laboratory tests alone cannot prevent hemorrhagic complications without immediate clinical management.
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
Rationale:
Measuring bilirubin levels using a transcutaneous bilirubinometer is the appropriate action when a newborn shows yellow skin tint. This noninvasive method quickly estimates bilirubin concentration, aiding in early detection of jaundice severity and guiding timely intervention. It helps determine if further treatment, such as phototherapy, is necessary, ensuring newborn safety and preventing complications like kernicterus.
B: Reviewing maternal blood type and Rh factor provides background on hemolytic disease risk but does not immediately assess the newborn’s current bilirubin level or jaundice severity, delaying urgent evaluation and intervention.
C: Preparing the newborn for phototherapy is premature without confirming bilirubin levels first; treatment decisions must be based on precise bilirubin measurements, not solely on visual assessment of jaundice.
D: Evaluating cord results offers limited immediate information on bilirubin status; it does not replace direct bilirubin measurement needed to assess jaundice severity and determine appropriate care steps.
A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge.
Rationale:
Continue prenatal vitamins with B12 while breastfeeding. This advice ensures the mother maintains adequate vitamin B12 levels, which is crucial for lacto-ovo vegetarians who might have limited dietary sources. Adequate B12 supports the infant’s neurological development and prevents deficiency-related complications during breastfeeding, promoting optimal infant health and maternal nutritional status.
A: Avoid using lanolin-based nipple cream or ointment does not apply since lanolin is safe and effective for nipple care and does not impact lactation or infant health.
B: Offer iron-fortified supplemental formula daily unnecessarily risks undermining exclusive breastfeeding benefits and iron needs are typically met through breast milk unless deficiency is diagnosed.
D: Weigh the baby weekly to evaluate the newborn’s growth is less practical than regular pediatric visits and may cause unnecessary parental anxiety without professional interpretation.
The nurse states to the newly pregnant patient, 'Tell me how you feel about being pregnant.' Which communication technique is the nurse using with this patient?
Rationale:
The nurse is using clarifying by asking the patient to explain her feelings about being pregnant. Clarifying invites the patient to elaborate or specify thoughts, ensuring understanding and preventing miscommunication. This technique encourages open dialogue, allowing the nurse to gain clearer insight into the patient’s emotional state and perspective, which is crucial during sensitive discussions like pregnancy.
B: Paraphrasing involves restating the patient’s words in the nurse’s own words to confirm understanding, which differs from the nurse’s direct question seeking elaboration.
C: Reflection repeats or mirrors the patient’s feelings or statements back to them, but the nurse’s question aims to gather more information, not mirror emotions.
D: Structuring organizes the conversation by setting an agenda or guiding topics, unlike this open-ended question inviting the patient’s personal response freely.
When teaching a gravid client how to perform kick (fetal movement) counts which instruction should the nurse includes.
Rationale:
If 10 kicks are not felt within 1 hr, drink orange juice and count for another hour.
This instruction is accurate because drinking orange juice can stimulate fetal movement due to its sugar content, thus encouraging the fetus to be more active. Counting movements for an additional hour ensures the mother accurately assesses fetal well-being before seeking further medical evaluation, enhancing fetal monitoring reliability during pregnancy.
A: Exercise for 15 before starting the counting to help increase fetal movement suggests physical activity, but it is not a standard or recommended practice for kick counts, potentially causing inconsistent results.
B: Count the movements once daily for one hour, before breakfast limits monitoring frequency; multiple daily counts provide more comprehensive assessment of fetal health and detect changes promptly.
C: Avoid caffeinated drinks for 24 hours before conducting the kick test is unnecessary as caffeine’s influence on fetal movement is minimal and not a routine precaution for kick count accuracy.
A pregnant patient arrives for her first prenatal visit at the clinic. She informs the nurse that she has been taking an additional 400 mcg of folic acid prior to becoming pregnant. Based on the patient's history, she has reached 8 weeks' gestation. Which recommendation would the nurse provide regarding folic acid supplementation?
Rationale:
The patient should be told that she no longer has to take additional folic acid because it will be included in her prenatal vitamins.
B: Since the patient is already at 8 weeks' gestation and has been taking extra folic acid, continuing supplementation is unnecessary as standard prenatal vitamins contain adequate folic acid to maintain proper levels for fetal development.
A: Have the patient continue to take 400 mcg folic acid throughout her pregnancy neglects that prenatal vitamins typically contain sufficient folic acid, making extra supplementation redundant at this stage.
C: Increasing folic acid intake to 1000 mcg unnecessarily raises dosage beyond recommended levels for low-risk pregnancies, which may not provide additional benefit and could cause potential side effects.
D: Scheduling an AFP test is unrelated to folic acid supplementation guidance and is typically conducted between 15-20 weeks gestation to assess neural tube defects, not at 8 weeks.
Which is the most important reason for evaluating the pattern of weight gain in pregnancy?
Rationale:
Evaluating the pattern of weight gain in pregnancy identifies potential nutritional problems or complications of pregnancy.
This is crucial because consistent monitoring helps detect deviations from expected weight gain, signaling possible issues like inadequate fetal growth or gestational diabetes. Early identification allows timely intervention, promoting maternal and fetal health, ensuring optimal nutrition, and reducing risks associated with poor pregnancy outcomes or complications tied to abnormal weight changes.
A: Prevents excessive adipose tissue deposits focuses narrowly on fat control, neglecting broader nutritional and health concerns essential during pregnancy.
B: Determines cultural influences on the woman's diet addresses social factors but does not directly relate to assessing pregnancy-related health risks through weight patterns.
C: Assesses the need to limit caloric intake in obese women targets only obese populations, missing the wider purpose of monitoring overall pregnancy health for all women.
A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
Rationale:
Monitor the fetal heart rate pattern.
Monitoring the fetal heart rate after spontaneous rupture of membranes is crucial to assess fetal well-being and detect any signs of distress or infection early. Clear fluid indicates no immediate concern, but continuous assessment ensures timely interventions if complications arise. This action prioritizes safety following membrane rupture during labor progression.
B: Perform a vaginal examination. A vaginal exam immediately after membrane rupture risks introducing infection and is unnecessary without new clinical indications.
C: Encourage the client to ambulate. Ambulation is not prioritized until fetal status is confirmed post-rupture, ensuring no fetal compromise before encouraging movement.
D: Administer pain medication. Pain medication is premature as contractions are mild and monitoring fetal response takes precedence before managing discomfort.
The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority?
Rationale:
Hypoglycemia has the highest priority for assessment in this newborn. The infant’s low birth weight and small size increase the risk of low blood sugar levels, which can cause serious neurological damage if not promptly identified and managed. Early detection and intervention are crucial to prevent complications associated with hypoglycemia in vulnerable neonates.
A: Hyperthermia Elevated body temperature is less immediately threatening in this case and lacks direct correlation with the newborn’s size and weight. It is less urgent compared to metabolic concerns in a small infant.
B: Hyperbilirubinemia Although jaundice risk exists, the physical measurements do not specifically indicate bilirubin issues requiring higher priority than glucose monitoring.
C: Polycythemia High red blood cell concentration is a concern but does not present with immediate danger as hypoglycemia does in a low-weight newborn.
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?
Rationale:
Obtain a specimen for urine analysis.
Urinary tract infections can stimulate uterine irritability and contractions, potentially leading to preterm labor. Early detection through urine analysis allows for prompt treatment, reducing risks to both mother and fetus. This initial step is critical to rule out infection as a reversible cause before implementing other interventions that address symptoms or complications.
A: Provide oral hydration Oral hydration helps reduce uterine irritability and contractions but does not identify underlying causes like infection, making it an incomplete first step in managing the client’s condition.
B: Have a complete blood count (CBC) drawn A CBC can detect infection or anemia but does not specifically target urinary tract infections, which are a more common cause of preterm contractions in pregnancy.
D: Place the client on strict bedrest Bedrest may decrease uterine activity but does not address possible infections or underlying causes, delaying necessary diagnostic evaluation and treatment that could prevent preterm labor.
During which phase of the cycle of violence does the batterer become contrite and remorseful?
Rationale:
The batterer becomes contrite and remorseful during the Honeymoon phase. This phase follows the violent incident, where the abuser often expresses regret, apologizes, and may show affection to regain trust. It temporarily reduces tension and gives the illusion of change, creating a cycle that traps victims in repeated abuse and reconciliation patterns, making it distinct from other phases.
A: Battering In this phase, violence and aggression peak, characterized by physical or emotional abuse, rather than remorse or apology, which contradicts the contrite behavior described.
C: Tension-building This phase involves escalating stress and irritability without remorse; it sets the stage for violence but lacks any contrition or reconciliation efforts.
D: Increased drug taking Increased substance use may exacerbate abusive behavior but does not inherently involve feelings of remorse or attempts at making amends.
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
Rationale:
The nurse should clarify the client's wishes about receiving blood products. Jehovah's Witnesses often refuse blood transfusions due to religious beliefs, so understanding the client's preferences ensures respect for autonomy and guides appropriate care decisions during postpartum hemorrhage management. This approach prioritizes informed consent and individualized treatment while addressing critical clinical needs sensitively.
A: Prepare to infuse multiple units of fresh frozen plasma assumes consent without verification, potentially violating the client’s religious beliefs and autonomy in critical care decisions.
B: Inform the client of the critical need for a blood transfusion overlooks the necessity of confirming the client’s personal or religious stance before recommending treatment.
D: Obtain consent from the family to infuse packed red blood cells disregards the client’s autonomy and legal rights to make decisions about her own medical care.
A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture lines. How should the nurse respond?
Rationale:
That's called caput succedaneum. It will absorb and cause no problems. Caput succedaneum is a swelling of the scalp that crosses suture lines due to pressure during delivery, commonly resolving without intervention. It is soft, edematous, and harmless, typically disappearing within a few days, making it a benign condition that does not require treatment or cause complications.
B: That is called a cephalohematoma. It cannot cross suture lines, so this option incorrectly identifies the swelling's nature and location. Cephalohematomas are confined beneath the periosteum and do not present as diffuse edema.
C: That is called a cephalohematoma. It can cause jaundice as it is. This option misidentifies the swelling crossing sutures; cephalohematomas do not cross sutures but can cause jaundice due to blood breakdown.
D: That is called caput succedaneum. It will have to be drained. Caput succedaneum is a self-limiting, harmless swelling that does not require drainage, making this treatment suggestion unnecessary and inappropriate.
The father of a 3-day old infant who is breastfeeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no appeared reason. What information is most important for the nurse to provide the father?
Rationale:
A fluctuation in hormones in the early postpartum period can cause mood changes. This explains the wife’s irritability, emotional instability, and difficulty coping as common, temporary symptoms of postpartum hormonal shifts, helping the father understand her behavior without unnecessary alarm, promoting empathy and appropriate support during this normal adjustment phase.
A: Contact the clinic if the behaviors continue for more than two weeks or becomes worse Suggests a future action without addressing the immediate cause or providing reassurance, missing the opportunity to explain the hormonal basis of the mood changes.
B: Tell the father count the newborns number of soiled diapers over the next few days Focuses on infant care monitoring, which doesn’t address the mother’s emotional state or explain her sudden mood changes, thus irrelevant to the father’s concern.
D: Recommend giving supplemental bottle feedings to the baby between breast feeding Proposes an unnecessary feeding intervention that does not relate to the mother’s mood symptoms and could undermine breastfeeding without addressing the behavioral issue.
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?
Rationale:
The nurse should instruct the client to use deep breathing during contractions. This non-pharmacologic method helps manage pain safely without adding more medication, especially since the client recently received butorphanol and promethazine, which can cause respiratory depression and sedation. Deep breathing promotes relaxation and coping during early labor while minimizing risks associated with additional narcotics or altering the oxytocin infusion.
A: Discontinue the Pitocin infusion Risks labor progression interruption and unnecessary intervention; current assessment shows active labor with 3 cm dilation, so stopping oxytocin is not warranted without complications.
B: Medicate the client with an additional 1 mg of Stadol IV push Re-dosing too soon may increase sedation and respiratory depression risk, considering Stadol’s peak effect and recent administration 30 minutes prior.
C: Notify the healthcare provider No urgent complications are evident requiring provider notification; the client’s condition is stable, and pain can be managed with non-drug techniques at this stage.
Changes in the diet of the pregnant patient who has phenylketonuria would include
Rationale:
Eliminating drinks containing aspartame is essential for pregnant patients with phenylketonuria because aspartame contains phenylalanine, which they cannot metabolize properly. Avoiding aspartame prevents harmful phenylalanine buildup, protecting fetal development from neurotoxicity and cognitive impairment associated with elevated phenylalanine levels during pregnancy, ensuring a safer gestational environment.
A: Adding foods high in vitamin C does not address phenylalanine metabolism or reduce phenylalanine levels, so it has no direct impact on managing phenylketonuria during pregnancy.
C: Restricting protein intake to less than 20 g daily is overly stringent and impractical; phenylketonuria management focuses on limiting phenylalanine, not total protein to this extreme degree.
D: Increasing caloric intake to at least 1800 calories daily does not specifically target phenylalanine control and is not a primary dietary modification for phenylketonuria in pregnancy.
Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse implement first?
Rationale:
Perform fundal massage until firm.
Fundal massage stimulates uterine contractions, which helps control postpartum hemorrhage by promoting uterine tone and reducing bleeding. A boggy uterus indicates uterine atony, the most common cause of postpartum hemorrhage, so massaging the fundus is the immediate priority to firm the uterus and minimize blood loss in this critical situation.
A: Have the client empty her bladder Bladder distention can cause uterine atony but massaging the fundus takes precedence to directly address bleeding and firmness before considering bladder status.
B: Inspect the perineum for lacerations Lacerations may cause bleeding, but a boggy uterus suggests atony, requiring immediate uterine contraction stimulation before assessing tissue trauma.
C: Increase oxytocin IV infusion Oxytocin promotes contractions but should follow manual fundal massage, which is the fastest initial intervention to restore uterine tone and reduce hemorrhage risk.
A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately?
Rationale:
Rapid increase in abdominal girth should be reported immediately as it may indicate ovarian hyperstimulation syndrome (OHSS), a serious and potentially life-threatening complication from fertility treatments like menotropins and hCG. Early recognition and intervention are crucial to prevent severe symptoms such as fluid accumulation, pain, and respiratory distress, ensuring prompt medical management and client safety.
A: Episodes of headache and irritability represent common but less urgent side effects; they do not signify immediate danger or require emergency intervention.
B: Nausea and vomiting are frequent mild adverse effects associated with fertility medications but lack the urgency linked to severe complications like OHSS.
D: Persistent daytime fatigue is a nonspecific symptom that, while uncomfortable, does not indicate an acute or life-threatening condition needing immediate attention.
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?
Rationale:
Supplementary iron is prescribed because it is difficult to consume 18 mg of additional iron by diet alone during pregnancy.
B: Pregnant women require significantly increased iron to support fetal development and maternal blood volume expansion, which diet alone rarely fulfills, necessitating supplementation for adequate iron levels and anemia prevention.
A: Supplementary iron utilization efficiency is not the primary reason for prescription; the challenge lies more in meeting increased iron demands through diet alone.
C: Iron absorption generally increases during pregnancy; decreased absorption is not a typical physiological change prompting supplementation.
D: Iron prevents iron-deficiency anemia, not megaloblastic anemia, which is caused by folate or B12 deficiency, making this option irrelevant.
The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
Rationale:
Position radiant warmer over the crib.
The infant’s symptoms—decreased muscle tone, respiratory difficulty, irritability, and mottled, cool skin—indicate hypothermia, a common issue in preterm infants requiring immediate warming to prevent further complications. Applying a radiant warmer is the priority intervention to stabilize temperature, improve oxygenation, and support metabolic function before addressing other concerns like glucose levels or feeding.
B: Assess the infant’s blood glucose level delays critical temperature regulation, allowing hypothermia to worsen, which can exacerbate respiratory distress and neurological instability in this vulnerable preterm infant.
C: Nipple feed 1 ounce 1% glucose in water risks aspiration and does not address the urgent need to correct hypothermia, possibly worsening respiratory difficulties first requiring thermal stabilization.
D: Place the infant in side-lying position does not adequately address the core problem of hypothermia and may delay essential warming measures, allowing symptoms to deteriorate further.
A client at 20 weeks gestation comes to antepartum clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client?
Rationale:
Pregnancy complications are not linked to HPV. HPV infection primarily causes genital warts and is not associated with adverse pregnancy outcomes or fetal harm. Management focuses on monitoring and symptom relief rather than aggressive treatment, as the virus often resolves or remains dormant. The infection does not necessitate pregnancy termination or specific antiviral therapy during gestation.
A: Termination of the pregnancy should be considered This advice is inappropriate since HPV infection does not pose a threat warranting pregnancy termination, as it generally does not affect fetal development or cause severe maternal complications.
C: This client should be treated with acyclovir (Zovirax) Acyclovir targets herpes simplex virus, not HPV; thus, it offers no therapeutic benefit for HPV-induced genital warts during pregnancy.
D: The client should be treated with penicillin G Penicillin G treats bacterial infections like syphilis, not viral infections like HPV; therefore, it is ineffective and irrelevant for managing vaginal warts caused by HPV.
A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
Rationale:
Direct Answer: Meet the mother's physical needs and demonstrate warmth toward the infant.
Correct Option Explanation: Addressing the mother’s physical recovery allows her to feel comfortable and supported, which facilitates emotional availability. Demonstrating warmth toward the infant encourages maternal-infant bonding by fostering a nurturing environment, promoting attachment, and enhancing early interactions crucial during the immediate postpartum period when bonding is most impactful.
A: Encourage the mother to provide total care for her infant Overwhelming a new mother with complete infant care immediately postpartum may cause stress and fatigue, hindering bonding due to physical exhaustion and lack of emotional readiness.
B: Provide privacy, so the mother can develop a relationship with the infant While privacy supports bonding, it alone neglects the mother’s physical recovery and emotional needs, which are essential for effective mother-infant interaction and attachment development.
C: Encourage the father to provide most of the infant's care during hospitalization Prioritizing paternal care overlooks the mother’s crucial early bonding period and may delay maternal attachment, which is vital for the newborn’s emotional security and maternal confidence.
Which goal is most appropriate for the collaborative problem of wound infection?
Rationale:
The most appropriate goal for the collaborative problem of wound infection is to monitor the patient to detect therapeutic response to antibiotic therapy. This goal focuses on evaluating the effectiveness of prescribed treatment, ensuring timely adjustments if necessary. Monitoring therapeutic response is essential in managing infections, preventing complications, and promoting recovery by assessing clinical signs and laboratory results specific to antibiotic efficacy.
A: The patient will not exhibit further signs of infection. This statement is outcome-based but lacks specificity about treatment monitoring, making it less actionable for collaborative care.
B: Maintain the patient's fluid intake at 1000 mL/8 hour. While hydration is important, it is unrelated to directly managing or assessing wound infection treatment.
C: The patient will have a temperature of 98.6°F within 2 days. This is a narrow physiological target and does not comprehensively address infection management or antibiotic therapy effectiveness.
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
Rationale:
The nurse should complete a sterile vaginal exam. A sterile vaginal exam assesses cervical dilation and effacement, helping determine labor progress and detect possible complications, especially with meconium-stained fluid present, guiding timely interventions for fetal and maternal safety.
B: Taking maternal temperature every 2 hours monitors infection risk but is not the immediate priority when meconium fluid and intact fetal heart rate are noted.
C: Preparing for an immediate cesarean birth is premature without assessing labor progression or fetal distress signs, which are not indicated by the current fetal heart rate.
D: Obtaining sterile suction equipment anticipates meconium aspiration but immediate evaluation of labor status through vaginal exam takes precedence for appropriate management.