Nursg Care of Infant Quiz

Quiz Answers 1 When would the nurse perform sterile vaginal examinations for Ms. Patton, who is in the latent phase of labor, has an unknown GBS status, and believes that her membranes have ruptured? Your Response: After entering the active phase of labor Rationale: Preterm premature rupture of membranes occurs when the membranes rupture before uterine contractions start and the woman is less than 37 weeks' gestation. Sterile vaginal examinations should be performed after a woman has entered the active phase of labor to prevent exposure to infection. 2 The nurse has a provider order to administer cefazolin sodium (Ancef) IV therapy for Ms. Patton. Which of the following would be included in this duty? (Select all that apply) Your Response: Monitor for diarrhea, dyspepsia, and abdominal cramps , Ensure that the correct cephalosporin is ordered , Note drug allergy history with the type of reaction Rationale: The nurse would look at the patient's history for any drug allergies and note the type of reaction, so that a contraindicated medication would not be given. The common adverse effects for cefazolin sodium are diarrhea, dyspepsia, and abdominal cramps; note that these effects are difficult to monitor in a laboring patient. There are many agents in the cephalosporin classification that look and sound alike, so the nurse would double check to ensure that the correct medication is administered. It is outside the nurse's realm to administer IV fluids or order laboratory tests without a provider order. 3 Brenda Patton was admitted to labor and delivery. Which patient findings would the nurse call the provider to report? (Select all that apply) Your Response: Maternal heart rate 105 beats per minute (bpm) , Oral temperature 102.2° F (39° C) Rationale: The nurse would report to the provider any of the following findings: a systolic blood pressure greater than 140 mm Hg, diastolic blood pressure greater than 90 mm Hg, oral temperature greater than 100.4° F (38° C), oxygen saturation less than 94%, meconium stained fluid, and maternal pulse greater than 100 bpm. Remediation: 4 The nurse is working with Ms. Patton during her labor. What would be the best approach by the nurse to support this patient to make her own decisions during this process? Your Response: Make statements that let the patient know that the well-being of her and her baby are important Rationale: The best approach by the nurse is to let the patient know that it is important that she take measures to provide physical well-being for herself and her baby. It is not helpful to tell a teenager in labor that she needs to finish school; however, during the postpartum period the nurse could facilitate the patient to think about how to achieve this developmental task. The adolescent needs to have the support of her family and friends and to not be isolated from her support system. The patient needs to receive education at a level that she can understand to make her own decisions, and having the health care providers manage her care without her informed decision is not the best approach. 5 During report, the labor and delivery nurse was informed that 18-year-old Brenda Patton, in active labor, had sporadic prenatal care and frequently cancelled appointments. Which of the following responses by the nurse would be most appropriate? Your Response: Examine own views about teen pregnancy to identify personal beliefs Rationale: The personal beliefs of the nurse could get in the way of providing nonjudgmental care to this adolescent patient. A nurse needs to examine his or her own beliefs and set aside personal moral convictions in order to provide effective nursing care. During prenatal care the teenager would be informed about the options that are available to provide care to the baby. The adolescent mother has the power to make decisions for her child. Approximately 25% of teenagers aged less than 18 years will have another baby within 2 years.