The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?

Inform the patient that they are in latent Labor.

Initiate Labor augmentation.

Prepare the patient for a caesarean delivery.

Anticipate admission to the Labor and delivery unit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.

Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.

Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.

Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.

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Correct Answer is D

Explanation

Choice A reason: Developing a plan of care with the child and family is important, but it does not explicitly address the need for cultural competence. This approach is cantered around collaboration rather than cultural sensitivity.

Choice B reason: Providing future-based care for culturally diverse children is vague and does not directly indicate an understanding or application of cultural competence in the current care situation.

Choice C reason: Treating all children the same regardless of their culture is contrary to the principles of culturally competent care. Culturally competent care involves recognizing and respecting the cultural differences that impact the child's health and tailoring the care to meet those unique needs.

Choice D reason: Assessing the child's culture and providing care based on the findings demonstrates an understanding and application of culturally competent care. This approach ensures that the care is respectful of and responsive to the cultural needs of the child and family.

A. Noodles with cheese sauce B. Yogurt with honey C. cooked broccoli D. Cut-up cherry tomatoes

Correct Answer is B

Explanation

Choice A reason: Cheese sauce may be high in fat and sodium, but noodles with cheese sauce are generally safe for an 11-month-old infant to consume in moderation. The primary concern for infants' diet is ensuring that foods are safe to swallow and do not pose a choking hazard, which noodles do not.

Choice B reason: Honey is not recommended for children under one year old due to the risk of botulism, a serious illness caused by a toxin produced by the bacterium Clostridium botulinum. Infants have underdeveloped immune systems that cannot fight off the toxin, making honey a potentially dangerous food choice for them.

Choice C reason: Cooked broccoli is generally a safe and nutritious food for an 11-month-old infant. It's a good source of vitamins, minerals, and fibre. However, it should be soft enough for the infant to chew and swallow without risk of choking.

Choice D reason: Cut-up cherry tomatoes are appropriate for an 11-month-old infant as long as they are cut into small, manageable pieces to prevent choking. Cherry tomatoes provide essential nutrients like vitamins A and C and can be a healthy addition to an infant's diet.

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The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The paediatric nurse is teaching the student nurse about culturally competent care. Which action will the student nurse identify as consistent with this type of care?

Correct Answer is D

Explanation

The nurse case manager is conducting a home visit for a family with an 11-month-old infant. When reviewing the infant's dietary intake, which food choice by the family requires further education by the nurse?

Correct Answer is B

Explanation

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