Durham: Chapter 2: Ethics and Standards of Practice Issues

A patient at 33 weeks gestation with a first pregnancy arrives at the labor and delivery unit with contractions. After monitoring the patient, the nurse determines the woman is in active labor and calls the health care provider (HCP), who prescribes a sleeping medication and sends the patient home. Which action does the nurse take? 1. Questions the HCP's prescribed treatment 2. Administers the medication and keeps the patient 3. Calls another HCP for a different prescription 4. Follows the HCP's instructions as prescribed

Ans: 1 Feedback 1 This is correct. According to the ANA Code of Ethics, the nurse promotes, advocates for, and strives to protect the health, safety, and rights of all patients. The nurse needs to question the HCP's prescribed treatment. 2 This is incorrect. Administering the prescribed medication and keeping the patient on the unit is in direct conflict with the HCP's prescription. The nurse should question the HCP's prescribed treatment. 3 This is incorrect. It is unprofessional for the nurse to call another HCP for different orders. If the nurse is not successful in getting the prescribed treatment changed, the nursing supervisor is notified to discuss concerns with the prescribing HCP. 4 This is incorrect. Once the nurse determines the patient is in active labor, the nurse needs to use the ANA Code of Ethics to guide nursing actions. Following questionable treatment prescriptions does not relieve the nurse of responsibility.

The nurse works in a postpartum maternal-newborn unit and notices a newborn who is exhibiting signs of distress. Through investigation, the nurse learns the newborn's mother has a history of abusing street drugs. Which facility system does the nurse report as being deficient? 1. Risk management 2. Newborn monitoring 3. Patient information 4. Admission process

Ans: 1 Feedback 1 This is correct. Of the options given, the deficiency is one related to risk management. A successful risk management program avoids preventable adverse outcomes and decreases the risk of liability through the use of appropriate, timely care, which accurately reflects maternal/fetal status before, during, and after interventions occur. 2 This is incorrect. The scenario does not contain information to support poor newborn monitoring. 3 This is incorrect. It can be assumed that patient information was available; however, the issue rests with the fact that it was not made readily to the postpartum nurse. 4 This is incorrect. The admission process is not likely the facility system that is deficient. Admission processes are not always performed by nurses; non-nursing personnel are not responsible for reporting concerns regarding risk management.

The nurse is experiencing an ethical dilemma when confronted with a situation in which either the mother or fetus is predicted to die. The nurse feels bound by the ANA Code of Ethics to protect both patients. Which aspect of care during an ethical dilemma will guide the nurse? 1. Maternity nurses are bound to advocate first and foremost for the well-being of the mother. 2. The nurse is ethically bound to provide the best care for both the mother and fetus. 3. If the fetus is viable and healthy, its survival is the priority of the maternity nurse. 4. Survival of the mother is solely based on both patient and family decision making.

Ans: 1 Feedback 1 This is correct. Practice dictates that the primary advocacy role of maternity nurses is on the behalf of the mother. 2 This is incorrect. Maternity nurses are expected to advocate for both maternal and fetal well-being; however, it is understood that it may not be to "do the right thing" for both. 3 This is incorrect. The loss of a healthy viable fetus is tremendous. However, during an ethical dilemma, the primary role of maternity nurses is on the behalf of the mother. 4 This is incorrect. It is never expected for the patient or family members to make a choice between the survival of the mother or the fetus.

The nurse is employed in a NICU. With each new admission, the neonate is classified in a specific category regarding care. The nurse is in the process of admitting a neonate at 22 weeks gestation with multiple life-threatening conditions involving both cardiac and respiratory systems. In which category of care does the nurse expect the neonate to be placed? 1. The category where aggressive care is probably futile. 2. The category where aggressive care is mostly uncertain. 3. The category where aggressive care is likely to be beneficial. 4. The category of "wait and see" to determine possible survival.

Ans: 1 Feedback 1 This is correct. The neonate is notably premature with complex issues involving two major, life-sustaining body systems. Aggressive care is probably futile, and the prognosis for a meaningful life is extremely poor or hopeless. 2 This is incorrect. Aggressive care for this neonate is definitely uncertain; however, because of prematurity and profound life-threatening conditions, the neonate's prognosis is extremely poor or hopeless. 3 This is incorrect. The condition of the neonate does not support the possibility of aggressive care being beneficial. 4 This is incorrect. There is no "wait and see" category in the care of compromised neonates in NICU

The nurse on a maternity unit is an Orthodox Jew whose rabbi teaches that pregnancy terminations are permitted only to save the life of the mother. Which situation becomes possible if the nurse puts aside personal values and assists with elective terminations? 1. Moral distress 2. Legal actions 3. Loss of spirituality 4. Professional dilemma

Ans: 1 Feedback 1 This is correct. When a nurse puts aside values and carries out an action believed to be wrong, it creates a situation of moral distress. 2 This is incorrect. If the nurse is assisting with elective pregnancy terminations in a legally identified location and manner, it is unexpected for the nurse to face legal actions. 3 This is incorrect. The nurse may or may not experience a loss of spirituality. The development of moral distress is most likely. 4 This is incorrect. The nurse may experience some type of personal dilemma; however, professional dilemma is not likely.

Which factors will facilitate the integration of evidence-based practice (EBP) in the maternitynewborn clinical setting? Select all that apply. 1. Frame clinical questions in PICOT format. 2. Collect the best and most relevant evidence. 3. Cultivate a spirit of inquiry in the workplace. 4. Encourage the use of trial and error methods. 5. Base practical decisions on nursing consensus.

Ans: 1, 2, 3 Feedback 1 This is correct. The PICOT question format will encourage unit nurses to think in scientific terms as they approach their daily work. The PICOT approach includes the important factors that need to be considered when implementing EBP information into the clinical setting. 2 This is correct. Collecting the best, most relevant evidence will facilitate implementing EBP research into the clinical setting. 3 This is correct. A spirit of inquiry is essential for fostering a desire to do things the right, evidence-based way. 4 This is incorrect. Trial and error is inappropriate in the clinical setting and may place patients, nurses, and facilities at ethical and legal risk. Changes in clinical practices need to be backed by research evidence. 5 This is incorrect. Deciding clinical practices by consensus may place patients, nurses, and facilities at both ethical and legal risk. Changes in clinical practices need to be backed by research evidence.

Parents of a neonate are grieving over their child's life-threatening disabilities. The neonate's course of treatment has changed three times in the last 24 hours due to irrational parenteral decisions. Which interventions will the NICU nurse implement in order to fulfill nursing responsibility to both the parents and the neonate? Select all that apply. 1. Inform the parents as to realistic expectations. 2. Use neonate's status with parenteral counseling. 3. Elicit parenteral input regarding medical care. 4. Advocate for medical support of the neonate. 5. Inform parents they are the final decision makers.

Ans: 1, 2, 4 Feedback 1 This is correct. The neonatal nurse has a responsibility to be truthful to the parents regarding realistic expectations for their neonate. The nurse also has a responsibility to cause no additional harm to the neonate. The ethical principle is for veracity. 2 This is correct. Again, the ethical principle of veracity (truthfulness) is important when counseling the parents of the neonate. The nurse is mindful of fulfilling nursing responsibility for both the parents and the neonate. 3 This is incorrect. Eliciting parenteral input regarding medical care of the neonate may fulfill a need for the parents to be involved in decision making; however, the possibility of causing the neonate additional harm or stress in increased with this action. 4 This is correct. The nurse has a responsibility to both the parents and the neonate to advocate for appropriate medical care of the neonate. Ethically, the nurse needs to do no harm. 5 This is incorrect. Informing the parents they are the final decision makers for their compromised neonate is not ethical. The parents may inadvertently cause additional distress to the neonate, or not be able to make appropriate decisions. The nurse needs to make sure the parents have access to medical professionals who can assist with decision making.

A nurse is suspended for refusal to participate in the performance of an elective termination of a pregnancy. Which specific group's standards does the nurse use for job reinstatement? 1. American Nurses Association (ANA) 2. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) 3. State board of nursing 4. Facility ethics committee

Ans: 2 Feedback 1 This is incorrect. American Nurses Association (ANA) has a code of ethics, which describes the goals, values, and obligations of nursing. The code applies to all nurses and is intended to be adaptable to areas of specialty. However, this group does not specifically address the nurse's concern. 2 This is correct. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) supports the protection of an individual nurse's right to choose to participate or decline in any reproductive health care service or research. The nurse needs to seek specific support from this group. 3 This is incorrect. State boards of nursing are responsible for defining the requirements of nursing education, licensure standards, and the scope of practice for all nurses within that specific state. 4 This is incorrect. The ethics committee for the facility is responsible for reviewing patient care cases that present ethical dilemmas or legal concerns

The nurse is providing care for a patient in active labor. The patient continuously asks the nurse for medication to "stop the pain." Which ethical principle does the nurse use when replying, "We need to protect the baby from being overmedicated. Let me help you with some breathing and relaxation techniques"? 1. Veracity 2. Beneficence 3. Nonmaleficence 4. Fidelity

Ans: 2 Feedback 1 This is incorrect. Veracity is the ethical principle dealing with being truthful with the patient about risks or admitting that the nurse needs assistance in providing appropriate care. Veracity is not the best description of the nurse's statement. 2 This is correct. Beneficence is the ethical principle related to doing good. The nurse is describing why additional medication is not given but is also offering to assist with other methods of pain management. 3 This is incorrect. Nonmaleficence is the ethical principle that supports avoidance of actions that will cause harm. The first part of the nurse's statement does address nonmaleficence, but the principle of beneficence is best supported by the complete statement. 4 This is incorrect. Fidelity is the ethical principle of being accountable and responsible for the care of the patient. This principle is most strongly related to handing off patient care to another nurse

The nursing department of a large facility is interested in improving clinical care with the introduction of EBP. Which barriers to EBP does the nursing department expect within the facility? Select all that apply. 1. Changes in nursing academia to include how to integrate research into practice 2. Outdated facility politics and policies that do not embrace research-based change 3. A general lack of information addressing nursing-focused research and change 4. Limited resources available to clinical care providers from nursing administration 5. Resistance by other health care professionals to providing nursing with autonomy

Ans: 2, 4 Feedback 1 This is incorrect. It is believed that nursing educational programs need to learn how to include EBP research in clinical care. Currently, the focus is on the rigorous process of performing research. However, this barrier is not managed within the health care facility. 2 This is correct. Many health care facilities have outdated political and policies, which can be a barrier to EBP. Nurses need the support, approval, and process by which to make EBP changes. This barrier can be managed within the facility. 3 This is incorrect. EBP applicable to the clinical site is readily available at this time and is not necessarily influenced by health care facilities. Barriers to EBP change is not based on available research, but on reluctance for facility involvement and management. 4 This is correct. A very real barrier to EBP at the clinical setting is the possibility of nursing administration failing to provide the resources needed to make changes in clinical care delivery. EBP may include provisions for resources, personnel, and training. 5 This is incorrect. Inadequate EBP knowledge and skills may exist with nurses and other health care professionals; however, it is not expected that resistance to nursing autonomy will become a barrier to EBP. The focus of all health care providers is on improvement of patient care and outcomes.

The labor and delivery nurse is providing care to a patient in active labor. The nurse notes EFM changes that suggest fetal distress and monitors the fetus for an additional 20 minutes before calling the health care provider. The health care provide determines that an emergency cesarean delivery is required. During transport, EFM is interrupted and not resumed due to expectations of an emergent procedure. A stillborn fetus is delivered. For which actions can the nurse be held legally responsible? Select all that apply. 1. Inappropriate use of oxytocin, causing fetal distress. 2. Lack of appropriate response to fetal compromise. 3. Inability to initiate resuscitation to a compromised fetus. 4. Delayed communication resulting in a delay of cesarean. 5. Performance of a technical error related to monitoring.

Ans: 2, 4, 5 Feedback 1 This is incorrect. There is no indication in the scenario that oxytocin was used during labor. 2 This is correct. The nurse can be held legally responsible for the lack of an appropriate response to fetal compromise. The nurse needs to immediately report indications of fetal compromise to colleagues, charge nurses, and/or health care providers. 3 This is incorrect. Prior to birth, resuscitation on a distressed fetus is not possible. 4 This is correct. Communication was delayed by at least 20 minutes of additional monitoring, which prolonged fetal distress. The nurse can be held legally responsible for the delay in emergency care. 5 This is correct. EFM was interrupted during transport and not reestablished for continued monitoring. The nurse can be held legally responsible for a technology error.

The nurse is providing care for a patient in labor. The unborn fetus was diagnosed with severe microcephaly at 20 weeks' gestation. The patient tells the nurse, "We want everything done to save our baby who has as much right to a good life as anyone else." Which ethical approach does this represent? 1. Autonomy 2. Libertarianism 3. Egalitarianism 4. Utilitarianism

Ans: 3 Feedback 1 This is incorrect. Autonomy is a patient's right to make health care decisions regardless of the outcome; however, autonomy is not considered specifically to be an ethical approach. 2 This is incorrect. Libertarianism is the ethical principle that promotes the idea that some people are more valuable to society than others, and those persons should be given the resources needed to survive. To do otherwise is seen as a waste of resources. 3 This is correct. Egalitarianism is the ethical principle being expressed by the patient. The principle focuses on the belief that all people are equal and resources should be distributed according to need. The focus is to protect the marginal or vulnerable members of society. 4 This is incorrect. Utilitarianism is the ethical principle that supports distributing resources to produce the greatest good for the greatest number of people. This principle opposes distribution of resources to only a few.

The nurse manager in the labor and delivery unit decides that all unit nurses are to take a course in electronic fetal monitoring (EFM) as recommended by AWHONN. Which is the most important issue related to EFM the nurse manager is expecting to address? 1. Eliminate the amount of litigation related to fetal injury. 2. Strengthen the staff's level of confidence with monitoring. 3. Reduce failure to accurately assess maternal and fetal status. 4. Improve the lack of communication with health care providers.

Ans: 3 Feedback 1 This is incorrect. One result of nurses taking a course of EFM may be a reduction (not elimination) of litigation related to fetal injury. However, a more important result will be the decrease in fetal injury. 2 This is incorrect. A course in EFM should increase the confidence of the labor and delivery nursing staff, but this is not the most important result the nurse manager is expecting. 3 This is correct. The most important issue the nurse manager expects to address with an EFM course is to reduce or eliminate the failure of nursing staff to accurately assess maternal and fetal status. 4 This is incorrect. Improvement of communication between the nurses and health care providers is not expected from a course in EFM; however, the quality of communication may improve.

An experienced OB nurse has accepted a position in labor and delivery of an inner-city hospital providing care for multicultural clients. Which action by the nurse is most helpful in preparation for this position? 1. Reviewing quantitative research focused on current birth procedures 2. Comparing facility policies with recent research recommendations 3. Intensely studying qualitative research focused on practice enhancement 4. Obtaining access to the department's recent research of evidence-based practice

Ans: 3 Feedback 1 This is incorrect. Reviewing quantitative research is one aspect of obtaining information regarding evidence-based practice (EBP). Although this research is valuable in keeping pace with current practice, it is not the action that will provide this nurse with information needed in preparation for this position. 2 This is incorrect. The nurse needs to be aware of facility policies; however, a comparison of the policies with recent research recommendations does not specifically prepare the nurse for this new position. 3 This is correct. The most helpful action by the nurse is to be aware of how the new workplace will affect the nurse's practice. It is important that the nurse review quantitative research addressing multicultural attitudes, understanding, and practices during childbirth. This is the most helpful action for preparation related to this job. 4 This is incorrect. At some point, the nurse wants to evaluate and/or access the department's recent research of EBP. However, this is not the most helpful action for job preparation.

The nurse in an obstetrician's office is discussing a patient's request for legally terminating an unwanted pregnancy after the fetus tests positive for Down syndrome. The woman and her spouse have five children from ages 11 to 17 years, and the family lives in an isolated rural area. Which action does the nurse take? 1. Inform the patient of programs to meet the needs of special children. 2. Share that children with Down syndrome can be high functioning. 3. Tell the physician of contextual factors identifying an ethical dilemma. 4. Inquire about the presence of an extended family support system

Ans: 3 Feedback 1 This is incorrect. The location of the family in an isolated rural area may add complexity and problems with regard to acquiring assistance with meeting the needs of a special needs child. 2 This is incorrect. It is true that some children with Down syndrome are high functioning. However, many are also born with other developmental and medical issues, which can cause financial, emotional, and medical care burdens. 3 This is correct. The situation includes conditions that cause an ethical dilemma. The nurse will inform the health care provider about the patient's request in regard to the ethical decision-making model related to contextual features. 4 This is incorrect. Family support of any kind may or may not exist. The availability of long-term care and support may not be possible.

The nurse in an OB's office is evaluating a patient who exhibits vaginal bleeding at 30 weeks gestation. The patient is prescribed bedrest at home and instructed to avoid lifting. The patient states, "I cannot go to bed, I have an 18-month-old at home." On which topic of the Jonsen model for ethical decision making will the nurse focus? 1. Contextual features 2. Quality of life 3. Patient preferences 4. Medical indications

Ans: 4 Feedback 1 This is incorrect. Contextual features are determined by multiple social factors, including, but not limited to, family dynamics, living situation of the patient, and cultural and religious beliefs of the patient and family. This topic does not specifically address the well-being of the patient and fetus. 2 This is incorrect. Quality of life requires consideration of how the proposed treatment will affect the patient's quality of life. This topic does not specifically address the well-being of the patient and fetus. 3 This is incorrect. Patient preference focuses on the expressed or presumed wishes of the patient, and includes respect for the patient's autonomy. This topic does not specifically address the well-being of the patient and fetus. 4 This is correct. Medical indications involve medical facts, including diagnosis, prognosis, treatment options, and how the patient can benefit, if at all, from the prescribed treatment. Of all four topics, this is the one that specifically addresses the well-being of the patient and the fetus.

The nurse works in the labor and delivery department. Which action by the nurse indicates a breach in the nursing care principles outlined by AWHONN? 1. Assists with an emergency delivery of a woman in a homeless shelter 2. Informs employer of religious beliefs against pregnancy termination 3. Suggests a nurse care for a patient who speaks the same native language 4. Declines a patient assignment because of a history of illegal drug use

Ans: 4 Feedback 1 This is incorrect. One AWHONN principle states nurses have a responsibility to provide high-quality, professional nursing care to all patients in emergency situations, regardless of the nurse's personal beliefs. The nurse's action is not a breach of this principle. 2 This is incorrect. An AWHONN principle states nurses have a professional obligation to inform their employers of any attitude or belief that can interfere with the nurse's essential job function. The nurse's action is not a breach of this principle. 3 This is incorrect. The nurse's action is not specifically addressed by an AWHONN principle; however, suggesting a nurse care for a patient who speaks a language familiar to the nurse is not inappropriate. An interpreter can still be obtained if needed. 4 This is correct. An AWHONN principle states that the nurse should not abandon a patient or refuse to provide care based on prejudice or bias. The nurse's action is a breach of this principle.

The nurse works in the maternal-newborn unit dedicated to management of high-risk pregnancy and delivery. A patient has delivered two children who died from a genetic disorder. The current pregnancy tests positive for the same disorder. Which ethical decision-making model will the nurse use with this patient? 1. The model that focuses on medical treatment 2. The model that focuses on patient preference 3. The model that focuses on religion and culture 4. The model that focuses on the quality of life

Ans: 4 Feedback 1 This is incorrect. The model that focuses on medical treatment may or may not be applicable for this patient. The patient has already lost two children to the same genetic disorder. Unless a new method of treatment is available, this is not the appropriate decision-making model. 2 This is incorrect. The actual patient in this scenario is uncertain, making the use of the patient preference model questionable. With a genetic disorder, the possibility of a lose-lose outcome is high. 3 This is incorrect. The model that focuses on finances, religion, and culture is based on contextual features. While consideration is necessary, this is not the most appropriate model for the nurse to use in this scenario. 4 This is correct. The most appropriate decision-making model in this scenario is the one that considers the quality of life. The important considerations involve the well-being of both the patient and the unborn fetus.

The nurse is assisting a patient in the use of an ethical decision-making model related to quality of life. Which question is inappropriate when using this model? 1. What are the prospects for a normal life? 2. Are arrangements made for prolonging life? 3. Which type of deficits for the patient are likely? 4. Does a present or future condition make life undesirable?

Ans: 2 Feedback 1 This is incorrect. With the use of the ethical decision-making model, a quality of life consideration is whether the patient will experience a normal life. 2 This is correct. When using the ethical decision-making model for quality of life, the question needs to address if there are plans for comfort or palliative care. It is inappropriate to question about the prolongation of life. 3 This is incorrect. Consideration must be given to the deficits that the patient is likely to exhibit and the impact on the patient's quality of life. Physical, mental, and social deficits should all be considered. 4 This is incorrect. The question of how present or future condition may affect the patient is important. The quality of life must be considered over a potential life span.