A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

Correct Answer: A

Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.

Correct Answer: C

Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.

Correct Answer: A

Rationale: The correct answer is A: Consume three to four servings of dairy each day. During the third trimester of pregnancy, calcium needs increase to support the baby's bone development. Dairy products are a rich source of calcium. Adolescents are still growing themselves, so adequate calcium intake is crucial for both the mother and baby. B: Increasing caloric intake by 600 to 700 calories is not specific to the third trimester and may lead to excessive weight gain, which can be harmful. C: Limiting sodium intake to less than 1 gram is not necessary during pregnancy, and some sodium is required for maintaining fluid balance. D: Increasing protein intake to 40 to 50 grams per day is important, but it is not specific to the third trimester and may vary based on individual needs.

Correct Answer: D

Rationale: The correct answer is D because all of the choices are risk factors for preterm labor. A: Urinary tract infection can lead to inflammation and contractions. B: Multifetal pregnancy puts more stress on the uterus, increasing the risk. C: Oligohydramnios is associated with a higher risk of preterm labor due to decreased amniotic fluid levels. In summary, all the choices contribute to the increased likelihood of preterm labor.

Correct Answer: D

Rationale: The correct answer is D because an axillary temperature of 37.7°C (99.9°F) in a newborn is above the normal range and could indicate a fever, which is a significant concern in newborns due to their immature immune systems. Fever in newborns can be a sign of serious infections that require immediate medical attention. A: Erythema toxicum is a common rash in newborns and typically resolves on its own without medical intervention. B: Failure to pass meconium stool by 48 hours may be a concern but not as urgent as a fever. C: Pink-tinged urine in the first few days of life is likely due to uric acid crystals and is considered normal in newborns.

Correct Answer: B

Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase. Summary: A: Active phase occurs when the cervix is dilated from 4 to 7 cm. C: Latent phase occurs when the cervix is dilated from 0 to 3 cm. D: Descent phase is not a recognized phase of labor.

Correct Answer: A

Rationale: The correct answer is A: Betamethasone. Betamethasone is a corticosteroid used to promote fetal lung maturity in preterm labor. In this scenario, at 32 weeks of gestation with placenta previa and active bleeding, the priority is to promote fetal lung maturity in case of premature delivery due to the risk of maternal hemorrhage. Indomethacin (B) is a nonsteroidal anti-inflammatory drug and not indicated in this situation. Nifedipine (C) is a calcium channel blocker used for preterm labor to delay contractions, not for placenta previa and active bleeding. Methylergonovine (D) is used for postpartum hemorrhage and not indicated in this scenario.

Correct Answer: D

Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.

Correct Answer: D

Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems. A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes. B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being. C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.