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":"D"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}
Explanation
Rationale:
- pH 7.40: A pH of 7.40 indicates that the client's acid-base balance is normal. This supports ventilation as the client’s respiratory system is effectively managing gas exchange.
- Blood pressure 112/77 mm Hg: This stable blood pressure is a sign that the client is adequately perfused, indicating management of hypovolemia. The blood pressure is now within a normal range, suggesting effective fluid resuscitation.
- PaCO2 42 mm Hg: The PaCO2 of 42 mm Hg is within normal limits, showing that the client's ventilation is adequate and confirming support of ventilation.
- Surgical dressing dry and intact: The intact dressing is important for preventing infection, as it ensures that there is no leakage or exposure to bacteria at the surgical site.
- Temperature 98.1° F (36.7° C): A temperature of 98.1° F (36.7° C is a normal and suggests successful rewarming or maintenance of normothermia, which contributes to Prevent infection as hypothermia can impair immune function and increase infection risk.
- Capillary refill 2 seconds: Capillary refill of 2 seconds is within normal limits and indicates good circulation and tissue perfusion, which is part of managing hypovolemia.
- Pain 0 on a scale of 0 to 10: The client’s report of no pain (pain score of 0) indicates that the goal of controlling pain and anxiety is being met, ensuring that the client is comfortable and stable.
Correct Answer is B
Explanation
A. Morphine: Morphine is used to relieve chest pain and anxiety in acute coronary syndromes. It acts as a vasodilator and analgesic, and there are no direct contraindications with recent sildenafil use, although blood pressure should still be monitored.
B. Nitroglycerin: Nitroglycerin is absolutely contraindicated in clients who have taken sildenafil within the past 24–48 hours. Both drugs are vasodilators, and their combination can lead to severe, life-threatening hypotension due to additive effects on vascular smooth muscle relaxation.
C. Aspirin: Aspirin is recommended in acute chest pain cases as it reduces platelet aggregation and helps prevent clot extension. It has no interaction with sildenafil and should not be withheld when myocardial ischemia is suspected.
D. Heparin: Heparin is an anticoagulant used in suspected myocardial infarction to prevent further clot formation. It does not have any adverse interactions with sildenafil and remains safe and beneficial in this context.
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