A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority
for the nurse to collect following an amniotomy?
Amniotic fluid color
The client's temperature
Frequency of contractions
Fetal heart rate
The Correct Answer is D
The priority data for the nurse to collect following an amniotomy is the fetal heart rate. This is an important nursing intervention to assess fetal well-being and identify any potential complications.
a) Assessing the color of the amniotic fluid is important, but it is not the highest priority.
b) Monitoring the client's temperature is important, but it is not the highest priority.
c) Assessing the frequency of contractions is important, but it is not the highest priority.
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Related Questions
Correct Answer is B
Explanation
b. "Everyone who lives in the home will need medication."
The nurse should inform the guardian that everyone who lives in the home will need medication when reinforcing teaching about enterobiasis. Enterobiasis, also known as pinworm infection, is highly contagious, and it can easily spread from person to person within the household. Treating only the affected individual may not be sufficient to eliminate the infection completely, as other household members may also be infected or at risk of reinfection.
Explanation for the other options:
a. "One dose of medication is all that will be necessary." Enterobiasis is typically treated with a medication regimen that involves taking multiple doses over a period of time. This is to ensure that all stages of the pinworm life cycle are targeted and eradicated. A single dose is usually not sufficient to eliminate the infection completely.
c. "Allow the child to take tub baths instead of showers." The choice of tub baths or showers does not directly impact the treatment or prevention of enterobiasis. Both methods of bathing can be used, but it is important to maintain good hygiene practices, such as regular handwashing and proper cleaning of the perianal area, to reduce the risk of reinfection.
d. "Wash all clothes and bed linens in cold water." While proper hygiene practices and laundering of clothes and bed linens are important in preventing the spread of enterobiasis, using cold water alone may not be sufficient. Washing clothes and bed linens in hot water (at a temperature of at least 60°C or 140°F) is recommended to kill any pinworm eggs that may be present.
Correct Answer is C
Explanation
MDMA, commonly known as ecstasy or Molly, is a stimulant drug that affects the central nervous system. It primarily acts on serotonin, dopamine, and norepinephrine neurotransmitters. The use of MDMA can lead to altered perception, increased sensory awareness, and hallucinations. Hallucinations may involve visual, auditory, or tactile sensations that are not based on reality.
The other findings mentioned—hypothermia (abnormally low body temperature), somnolence (excessive sleepiness), and muscle weakness—are not typically associated with MDMA use. Instead, MDMA use may lead to increased body temperature (hyperthermia), increased energy levels, agitation, increased heart rate, and muscle tension.
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