A nurse is planning care for a client in labor and delivery. Which of the following activities should the nurse plan to demonstrate working at the highest level of their license?
Fetal heart monitoring
Taking specimens to the lab
Performing vaginal delivery
Giving a client bed bath
The Correct Answer is C
A) Fetal heart monitoring:
Nurses are trained to monitor fetal heart rates, interpret patterns, and identify signs of distress, but this task is typically within the scope of a registered nurse's (RN) practice. It may not involve the critical decision-making or advanced skills associated with the highest level of licensure.
B) Taking specimens to the lab:
Taking specimens to the laboratory is a necessary but routine part of care. While it is important for ensuring proper diagnostic testing, it is a lower-level task and does not demonstrate the highest level of nursing practice. This task is often delegated or performed as part of standard nursing duties.
C) Performing vaginal delivery:
Performing a vaginal delivery is a high-level skill that typically requires advanced education, certification, and licensure beyond that of a registered nurse. This is usually performed by a midwife, obstetrician, or other healthcare providers with advanced training and certification. In many settings, a registered nurse may assist with vaginal deliveries but cannot independently perform them unless they have additional certifications (such as Certified Nurse Midwife).
D) Giving a client a bed bath:
While important for patient care and comfort, giving a client a bed bath is a basic nursing task that does not demonstrate working at the highest level of licensure. It is a fundamental nursing activity often carried out by nurses, nursing assistants, or other support staff. The act of providing a bed bath is part of the foundational skill set and does not require advanced knowledge or decision-making that would demonstrate the highest level of practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
Given:
Desired dose: Digoxin 0.25 mg PO daily
Available concentration: Digoxin 500 mcg/10 mL
To find:
Volume to administer (in mL)
Step 1: Convert desired dose to micrograms
We know that 1 milligram (mg) is equal to 1000 micrograms (mcg). Therefore, to convert the desired dose from mg to mcg, we multiply by 1000:
Desired dose (mcg) = Desired dose (mg)x 1000
Desired dose (mcg) = 0.25 mg x 1000 = 250 mcg
Step 2: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 3: Substitute the values
Plugging in the given values, we get:
(250 mcg) / (500 mcg/10 mL) = Volume to administer
Step 4: Simplify
To simplify, we can invert the denominator and multiply:
(250 mcg) x (10 mL / 500 mcg) = Volume to administer
The "mcg" units cancel out, leaving us with:
(250 x 10 mL) / 500 = Volume to administer
Step 5: Calculate
Performing the multiplication and division, we get:
2500/ 500 = Volume to administer
5 mL = Volume to administer
Correct Answer is A
Explanation
A) Check fetal heart rate:
The first priority when a woman's membranes spontaneously rupture is to assess fetal well-being. The nurse should immediately check the fetal heart rate (FHR) after the rupture of membranes to evaluate for any signs of fetal distress. If there are any concerns regarding the FHR, further interventions may be needed, such as adjusting the maternal position or preparing for a possible emergent delivery. Monitoring the FHR will help guide subsequent decisions regarding care.
B) Instruct her to bear down with the next contraction:
While the second stage of labor involves pushing, it is important to wait for the appropriate signs of readiness before instructing the mother to bear down. The nurse should ensure the cervix is fully dilated and that fetal descent is progressing appropriately. Rushing into pushing too early or without proper readiness can lead to maternal and fetal complications.
C) Place her legs in stirrups:
Placing the mother’s legs in stirrups is typically done once she is in the active phase of pushing (typically when the cervix is fully dilated and fetal descent is ready). It is not the first priority immediately after the membranes rupture. The nurse should first assess the fetal heart rate and ensure the woman is comfortable and ready to push before assuming the lithotomy position or placing her legs in stirrups.
D) Test a sample of the amniotic fluid for meconium:
Testing the amniotic fluid for meconium should be done if there is concern that the amniotic fluid may be stained, as meconium in the amniotic fluid can be a sign of fetal distress. However, the first action after the membranes rupture is to check the fetal heart rate. If the FHR is normal, further actions, like testing the fluid, may follow, but the priority remains assessing fetal well-being.
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