When caring for a woman whom a nurse suspects is being abused by her partner, the nurse should do which of the following?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Ask the client directly about how she sustained her injuries. This is because when a nurse suspects that a woman is being abused by her partner, it is crucial to directly address the issue and provide an opportunity for the woman to disclose information about the abuse. By asking the client directly, the nurse can open up a dialogue, express concern for her well-being, and offer support and resources. Option B) Counsel the client on how her behavior probably provoked the attack is incorrect and harmful as it blames the victim for the abuse, which is never acceptable. Victim blaming can further traumatize the woman and discourage her from seeking help. Option C) Inform the client that the police must arrest her partner is incorrect as it may not be safe or feasible for the woman to involve the police at that moment. Safety of the woman should be the top priority, and decisions regarding involving law enforcement should be made with her consent and safety in mind. Option D) Give the client a pamphlet with the names of matrimonial attorneys is also incorrect as it does not address the immediate safety concerns of the woman. Providing legal resources should come after ensuring the woman's safety and well-being are secured. In an educational context, it is essential to teach healthcare professionals the importance of recognizing and responding to signs of intimate partner violence sensitively and effectively. Nurses should be trained to approach these situations with empathy, understanding, and a focus on the well-being and safety of the woman. Direct communication and offering support and resources are key components of providing appropriate care in cases of suspected abuse.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take first is to choose option B) Stop the infusion and remove the catheter. This is the most appropriate immediate response to an infiltrated IV as it helps prevent further harm to the patient. Stopping the infusion will prevent any more of the medication from entering the surrounding tissues, reducing the risk of tissue damage, infection, or other complications. Removing the catheter promptly is essential to prevent further infiltration and minimize the potential for adverse effects. The other options are incorrect in this context: A) Determining whether the infusion is a vesicant is important but not the immediate priority when an IV has infiltrated. C) Documenting the occurrence in the medical record is necessary but should be done after addressing the immediate issue. D) Elevating the extremity and monitoring the site can be done after removing the catheter but is not the initial step to take. In an educational context, understanding the correct response to an infiltrated IV is crucial for nurses caring for patients receiving IV medications, especially in high-risk situations like pregnancy. This knowledge ensures patient safety and prevents potential complications associated with IV therapy.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Caffeinated coffee. The nurse should remove caffeinated coffee from the client's food tray because Mormons typically abstain from consuming caffeine as part of their religious beliefs. Caffeine is considered a stimulant and is avoided by many members of the Mormon faith. Option B) Cheeseburger, option C) Fried fish, and option D) Pork sausage do not need to be removed from the client's food tray based on religious beliefs. While dietary preferences can vary among individuals, there is no specific restriction within Mormonism against the consumption of cheeseburgers, fried fish, or pork sausage. From an educational standpoint, this question highlights the importance of cultural competence and respecting an individual's religious beliefs and dietary practices in healthcare settings. Understanding and accommodating a patient's cultural and religious preferences can contribute to providing patient-centered care and promoting trust between healthcare providers and patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Decrease in variability. Meperidine (Demerol) is an opioid analgesic that can cross the placental barrier and affect the fetus. Opioids can lead to central nervous system depression in both the mother and the fetus, resulting in a decrease in variability on the fetal heart monitor tracing. Variability is an important indicator of fetal well-being, so a decrease in variability can be concerning. Option A) Drop in baseline heart rate is not typically associated with meperidine administration, as opioids usually do not cause a direct drop in the baseline fetal heart rate. Option B) Increase in number of variable decelerations is not a common effect of meperidine. Variable decelerations are usually associated with cord compression, not opioid administration. Option D) Rise in number of early decelerations is also not a typical response to meperidine. Early decelerations are often considered benign and are associated with head compression during contractions. It is crucial for nurses and healthcare providers to understand the effects of medications on both the mother and fetus during pregnancy to provide safe and effective care. Monitoring fetal well-being during labor is essential to ensure timely intervention if any abnormalities are detected, especially when medications like opioids are involved.

Correct Answer: D

Rationale: In this scenario, the correct question the nurse should ask the client is option D) "Do you have a headache or blurring of your vision?". This is the correct choice because the client's elevated blood pressure of 150/110, especially when compared to her previous readings, could be indicative of postpartum preeclampsia, a serious condition characterized by high blood pressure and often accompanied by headaches and visual disturbances. Option A) "Have you had a bowel movement since delivery?" is incorrect because it is not directly related to the client's elevated blood pressure and does not address the urgent need to assess for signs of preeclampsia. Option B) "Is there anything that is making you anxious about the baby?" is also incorrect as it does not address the immediate health concern of the client's high blood pressure and potential signs of preeclampsia. Option C) "When you last went to the bathroom were you bleeding heavily?" is not the most appropriate question at this time as it does not directly address the client's current blood pressure and symptoms that could indicate a serious complication like preeclampsia. In an educational context, it is crucial for nurses to be able to recognize signs and symptoms of postpartum complications, such as preeclampsia, and to ask targeted questions to assess and manage these conditions promptly. Understanding the significance of changes in vital signs and knowing which questions to ask can lead to early detection and intervention, ultimately improving maternal and neonatal outcomes.