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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}
Explanation
Rationale:
- Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
- Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
- Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
- Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.
Correct Answer is ["B","C"]
Explanation
A. Contagious until symptoms subside: Streptococcal pharyngitis is contagious until 24 hours after starting antibiotics, not until all symptoms are gone. This is important for limiting transmission to others in the household or school setting.
B. Sandpaper-like rash: A sandpaper-textured rash is a hallmark sign of scarlet fever, which is a complication of strep throat. It usually begins on the neck or chest and spreads, often feeling coarse to the touch.
C. Peeling and flaking skin in a week: Desquamation, or skin peeling, is common several days after a strep rash subsides, particularly on the hands and feet. This symptom signals the healing phase of scarlet fever.
D. Darkening of skin under arms: Darkened underarm skin is typically linked to acanthosis nigricans, associated with insulin resistance or obesity. It is not seen with streptococcal infections or fever-related conditions.
E. Fever lasting for 7 to 10 days: Fever from strep throat usually resolves quickly within 24–48 hours of initiating antibiotic therapy. Prolonged fever would be atypical and requires further evaluation for complications.
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