The labor process is an exciting and anxious time for the patient and her partner and family
In a relatively short period of time, they experience one of the most profound changes in their lives. Nursing care management focuses on assessment and support throughout labor and birth, with the goal of ensuring the best possible outcome for mother and newborn. Please match each nursing diagnosis with the appropriate intervention needed to achieve the expected outcome.
a. Anxiety related to labor and the birthing process
b. Acute pain related to contractions
c. Risk for impaired urinary elimination
d. Risk for impaired individual coping
e. Fatigue related to energy expenditure during labor and birth
53. Instruct the patient and partner in the use of specific relaxation techniques.
54. Continue to provide comfort measures and minimize distractions.
55. Group care activities as much as possible.
56. Orient the patient and family to the labor and birth unit.
57. Encourage frequent voiding and catheterize if necessary.
53. ANS: B
54. ANS: D
55. ANS: E
56. ANS: A
57. ANS: C
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The nurse is reviewing concepts related to one's heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as:
a. Culture. b. Religion. c. Ethnicity. d. Spirituality.
One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best?
A) "I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." B) "The voices are part of your illness and they will leave in time." C) "This guarding responsibility can make you tired. You rest for now, and I'll guard a while." D) "You are just imagining these things. Do not pay any attention to the voices."
A prescription containing various medicines issued by a physician for a client with typhoid appears incorrect to a nurse. Which is an appropriate action for the nurse?
A) Administer the client medicines according to the prescription B) Administer the recommended dosage of the medication C) Notify the physician that the order needs correction D) Rectify the prescription on his or her own
A client receives metronidazole (Flagyl) for treatment of a vaginal yeast infection. What should the nurse include in medication education for this client?
1. Do not drink alcohol with this medication. 2. Do not take this medication with milk or milk products. 3. Drink at least 3000 mL of fluid per day with this medication. 4. Do not become pregnant while taking this medication. 5. You may experience a metallic taste while on this medication.