A gravida 2 para 1 (G2P1) at 38-weeks gestation who is scheduled for a repeat cesarean section in one week is brought to the labor and delivery unit experiencing contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, "I've had 8 children and I know she is in labor.I want her to have her cesarean section right now!" Which action should the nurse take?

Request that the mother leave the room.

Notify the charge nurse of the situation.

Request security to remove her from the room.

Tell the mother to stop speaking for the client.

Answer and Explanation

The Correct Answer is A

A. Request that the mother leave the room: The nurse should prioritize the patient’s needs and comfort, the nurse should calmly request that she leave the room. This allows the nurse to focus on the client’s condition without interference and ensures that the client’s autonomy and wishes are respected.

B. Notify the charge nurse of the situation: While notifying the charge nurse may be appropriate if the situation escalates, the nurse should first try to address the issue directly by requesting that the mother leave the room.

C. Request security to remove her from the room:Security should be a last resort. The situation can likely be handled by the nurse in a calm, respectful manner without the need for security intervention, unless the behavior becomes aggressive or threatening.

D. Tell the mother to stop speaking for the client: This could be perceived as confrontational and disrespectful. It is more effective for the nurse to address the mother’s disruptive behavior by requesting she leave the room so that the client’s privacy and autonomy can be maintained.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "You didn't do anything wrong.” This statement is well-intended, but may minimize the parent’s emotional experience. It’s important to acknowledge the parent’s feelings rather than just reassuring them. This response does not invite further expression of their emotions.

B. "This must be a very difficult time for you." This response acknowledges the parent's emotional distress and validates their feelings, creating an opportunity for them to express their concerns. It provides emotional support and opens the door for further discussion.

C. "Is there any particular reason why you think this is your fault?" While it may be important to understand the parent’s concerns, this response is confrontational. It may inadvertently make the parent feel blamed, which could worsen their state instead of comfort.

D. "With surgery, your baby should have a full recovery." This response may give false hope and oversimplifies the complexities of myelomeningocele. Recovery outcomes depend on various factors. The focus should be on providing emotional support rather than making promises.

A. Blood alcohol level of 0.09% (19.5 mmol/L). B. Weight loss of 10 lb (4.5 kg) in past month. C. Six hours of sleep in the past three days. D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L).

Correct Answer is D

Explanation

A. Blood alcohol level of 0.09% (19.5 mmol/L): This alcohol level indicates mild intoxication. It can cause slurred speech and gait changes, but the effects are usually transient and less concerning than drug toxicity. It should be monitored, but is not as urgent as lithium toxicity.

B. Weight loss of 10 lb (4.5 kg) in past month: This degree of weight loss may suggest poor nutritional intake or a depressive episode, but it is not immediately life-threatening. It requires follow-up but does not explain the acute neurological signs the client is exhibiting.

C. Six hours of sleep in the past three days: Severe sleep deprivation can exacerbate mood instability in bipolar disorder, but it does not account for slurred speech or gait disturbances. This concern is significant for mental health management but not the priority in this situation.

D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L): This is above the therapeutic range and suggests lithium toxicity, which can cause neurological signs such as slurred speech and ataxia. Immediate reporting is crucial to prevent progression to more severe toxicity, including seizures or coma.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.