The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:
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Solution
Wash her hands for 2 minutes before care
The best way to prevent post-operative wound infection is hand washing.
Option A: Use of prescribed antibiotics will treat infection, not prevent infections.
Options C and D: Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
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Solution
Checking the client’s blood pressure
Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes.
Option A: The client can be checked for cervical dilation later after she is stable.
Option B: The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing.
Option D: Fetal heart tones should be assessed after the blood pressure is checked.
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
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Solution
Wrapping the newborn snugly in a blanket
The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience.
Options A and D: Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time.
Options C: Placing the infant in an infant seat is incorrect because this will also cause movement that can increase muscle irritability.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
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Solution
Active
The active phase of labor occurs when the client is dilated 4–7cm.
Options B and D: The latent or early phase of labor is from 1cm to 3cm in dilation.
Options C: The transition phase of labor is 8–10cm in dilation.
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
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Solution
Fetal heart tones
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported.
Options A, C, and D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
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Solution
Within 72 hours of delivery
To provide protection against antibody production, RhoGam should be given within 72 hours.
Options B, C, and D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
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Solution
Low birth weight
Infants of mothers who smoke are often low in birth weight.
Option B: Infants who are large for gestational age are associated with diabetic mothers.
Option C: Preterm births are associated with smoking, but not with appropriate size for gestation.
Option D: Growth retardation is associated with smoking, but this does not affect the infant length.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
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Solution
Her contractions are 5 minutes apart.
The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding.
Options A and B: She should not wait until the contractions are every 2 minutes or until she has a bloody discharge.
Option C: Has a vague answer and can be related to a urinary tract infection.
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
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Solution
Assess the fetal heart tones
The symptoms of painless vaginal bleeding are consistent with placenta previa.
Option B: Cervical check for dilation is contraindicated because this can increase the bleeding.
Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones.
Option D: A detailed history can be done later.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
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Solution
Positive HIV
Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk.
Options A, C, and D: The clients with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.