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?

Correct Answer: B

Rationale: The correct answer is B) Fidelity. Fidelity refers to the ethical principle of being faithful and true to one's commitments and promises. In this scenario, the nurse violated fidelity by assuring the patient that everything would be okay without having certainty or control over the outcome. This breach of trust led to a sense of betrayal for the patient when the outcome was tragic. Option A) Autonomy pertains to respecting the patient's right to make their own decisions. In this case, the nurse did not violate the patient's autonomy but failed in maintaining fidelity. Option C) Beneficence involves acting in the patient's best interest. While the nurse's intention may have been to provide comfort, the lack of truthful information compromised beneficence. Option D) Accountability refers to the responsibility of healthcare professionals for their actions. While accountability is important, the primary ethical principle violated in this scenario is fidelity. In an educational context, this scenario highlights the significance of honesty and transparency in patient communication, especially in high-stress situations. Nurses must balance providing reassurance with being truthful and realistic to maintain trust and uphold ethical principles like fidelity in their practice.

Correct Answer: C

Rationale: In this scenario, the correct intervention is to obtain a specimen for urine analysis (Option C) first. The client's symptoms suggest a possibility of a urinary tract infection (UTI) or other urinary issues, which can contribute to uterine irritability and contractions. By analyzing the urine, the nurse can assess for any signs of infection or other abnormalities that may be causing the client's symptoms. Providing oral hydration (Option A) is important for pregnant clients, but in this case, addressing the potential underlying issue takes precedence. Having a complete blood count (CBC) drawn (Option B) may be necessary at some point, but it is not the initial priority. Placing the client on strict bedrest (Option D) is not supported as the first intervention without further assessment. In an educational context, this question highlights the importance of assessing and addressing potential medical issues that can impact maternal and fetal health during pregnancy. Understanding the implications of different symptoms and prioritizing interventions based on assessment findings are crucial skills for nurses caring for maternal and reproductive health clients.

Correct Answer: A

Rationale: The correct answer is A) Between the time the temperature falls and rises. This temperature pattern indicates the occurrence of ovulation, which is crucial for conception. Basal body temperature typically drops just before ovulation and then rises and remains elevated after ovulation. This shift in temperature signifies the release of an egg and the fertile window for conception. Option B) Between 36 and 48 hours after the temperature rises is incorrect because ovulation usually occurs before the temperature rises, not after. Therefore, this timing would not align with the fertile window for conception. Option C) When the temperature falls and remains low for 36 hours is incorrect because a sustained low temperature does not indicate ovulation. Ovulation is typically associated with a temperature rise, not a prolonged low temperature. Option D) Within 72 hours before the temperature falls is incorrect because ovulation occurs before the temperature falls. Therefore, this timing would not align with the fertile window for conception. In an educational context, understanding basal body temperature patterns is essential for women who are trying to conceive. By tracking these patterns accurately, women can identify their most fertile days and optimize their chances of conception. Education on this topic empowers women to take control of their reproductive health and make informed decisions regarding family planning.

Correct Answer: C

Rationale: The most effective instruction to prevent nipple soreness for a breastfeeding mother is to correctly place the infant on the breast (Option C). This is crucial because proper positioning and latching ensure that the baby is effectively extracting milk without causing damage to the mother's nipples. When the baby is positioned correctly with a deep latch, nipple soreness is minimized as the baby is able to feed efficiently. Option A, wearing a cotton bra, is not directly related to preventing nipple soreness during breastfeeding. While wearing a comfortable bra is important for overall breast health, it does not address the root cause of nipple soreness. Increasing nursing time gradually (Option B) may not necessarily prevent nipple soreness. The key factor is the correct latch and positioning rather than the duration of nursing sessions. Manually expressing a small amount of milk before nursing (Option D) is not as effective as ensuring correct placement of the infant on the breast. While expressing some milk before nursing can help with engorgement or if the baby is having difficulty latching, it is not the primary method to prevent nipple soreness. In an educational context, it is vital for healthcare professionals to emphasize proper breastfeeding techniques to prevent common issues like nipple soreness. By understanding and promoting correct latch and positioning, nurses can support mothers in establishing a successful breastfeeding relationship with their infants, leading to better outcomes for both mother and baby.

Correct Answer: C

Rationale: In the context of maternal and reproductive health, the correct answer is C) The cervix is completely dilated. This is because full cervical dilation (10 cm) indicates that the cervix is fully prepared for the pushing stage of labor. At this point, the client's body is physiologically ready for the second stage of labor, which involves pushing to facilitate the birth of the baby. Option A) There is only an anterior or posterior lip of cervix left is incorrect because the presence of even a small part of the cervix that is not fully dilated can obstruct the descent of the baby and hinder the progress of labor. Option B) The client describes the need to have a bowel movement is incorrect because the urge to push due to feeling like having a bowel movement may not necessarily indicate full cervical dilation and readiness for the pushing stage of labor. Option D) The cervix is completely effaced is incorrect because cervical effacement, which refers to the thinning of the cervix, is important for labor progress but not a direct indicator of the readiness to begin pushing. In an educational context, it is crucial for nurses to understand the significance of cervical dilation in guiding the management of laboring clients. Recognizing the signs of full dilation ensures that the pushing stage commences at the appropriate time, promoting effective labor progress and optimal maternal and fetal outcomes.