OB nursing concepts 2
What does the nurse tell a pregnant client with genital herpes simplex virus (HSV) infection about the risk or adverse effect on her pregnancy?
"The infant may have neonatal herpes after birth." The most severe complication of HSV infection in pregnant women is neonatal herpes, a potentially fatal or severely disabling disease occurring in infants with maternal infection. Stillbirth is not a complication, but there is an increased chance of miscarriage in the first trimester of pregnancy. Congenital infection is rare but sometimes possible.
Researchers have described three phases of mental health consequences of sexual assault. How are the three phases described?
Acute phase: disorganization, Outward Adjustment phase, and Long-Term Process: reorganization phase The three phases of mental health consequences of sexual assault include: Acute phase: disorganization, Outward Adjustment phase, and Long-Term Process: reorganization phase.
Which intervention would be most beneficial to a pregnant client with cervical Chlamydia trachomatis?
Administering azithromycin (Zithrocin) 1 g orally once a day to the client. Azithromycin (Zithrocin) 1 g orally once a day is recommended for the treatment of Chlamydia infection in pregnant women. Administering this drug would help in preventing ophthalmic neonatorum in the fetus at birth. HPV (Gardasil) vaccine is administered for prophylaxis of human papillomavirus infection in humans. Doxycycline (Doryx) 100 mg twice a day is the prescribed dosage for treatment of Chlamydia infection in nonpregnant women. Silver nitrate drops are instilled in the eyes of the neonate to prevent Chlamydia trachomatis infection. However, they do not prevent perinatal transmission of this infection.
The nurse suspects that a client has syphilis and assesses the client's nontreponemal antibody test results. The test results are negative. What action does the nurse take?
Administers the test again after 2 months. In early primary syphilis, clients may have nonreactive serologic tests. Seroconversion usually takes place 6 to 8 weeks after exposure. Therefore, the nurse should repeat the test 1 to 2 months later, when a suggestive genital lesion exists. Assessing the client's medical history will provide determinative information regarding whether the client is in fact infected. Genital lesions may appear later and will not help confirm the presence of syphilis now.
Sexual assault is considered what?
An act of force in which an unwanted and uncomfortable sexual act occurs. Sexual assault encompasses a wide range of sexual victimization, including unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts. It may include but is not limited to rape. Sexual violence is a term for rape, not for sexual assault, which includes a broader range of activities. A sexual act of violence, or rape, may be categorized as sexual assault. Statistically, the victim knows the assailant.
A client who is pregnant also has a history of psoriasis. What information can the nurse provide to the client relative to this disease process?
Clients who have psoriasis during pregnancy experience a varied response. Psoriasis typically gets worse in about 20% of women who are pregnant. Psoriasis during pregnancy presents with a variable response—some have no change, some get better and some get worse. There is no direct correlation between sunlight and psoriasis.
The nurse observes that eclampsia has developed in a pregnant client after starting magnesium sulfate therapy. What action does the nurse take?
Continue to administer magnesium sulphate per protocol. The nurse needs to administer additional magnesium sulfate, because it will help in treating eclamptic seizures and preventing repeated seizures. Regional anesthesia is not recommended for eclamptic clients due to the risk of maternal complications. Calcium gluconate is administered as an antidote for magnesium toxicity. Immediate cesarean birth is a priority when the client is in shock after a trauma.
The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms should the nurse expect to observe? Select all that apply.
Decreased urinary output and irritability Transient headache and +1 proteinuria Ankle clonus and epigastric pain Platelet count of less than 100,000/mm3 and visual problems. Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.
The Centers for Disease Control and Prevention (CDC)-recommended medication for the treatment of chlamydia is what?
Doxycycline is effective for treating chlamydia; however, it should be avoided if a woman is pregnant. Podofilox is a recommended treatment for nonpregnant women diagnosed with human papillomavirus infection. Acyclovir is recommended for genital herpes simplex virus infection. Penicillin is not a CDC-recommended medication for chlamydia; it is the preferred medication for syphilis.
What is a common reason for Japanese women to hold back reporting intimate partner violence (IPV)?
Fear of escalating violence. Women belonging to the Japanese culture may not disclose about IPV due to the fear of escalating violence, shame, and victim blaming. Women belonging to the urban Bangladesh culture do not disclose IPV due to fear of community retaliation. Vietnamese women do not disclose IVP, because they fear that this would cause disharmony in the family. Women belonging to Bhutanese, Indian, and Sri Lankan cultures feel that men have the right to abuse and may not disclose IVP.
A client comes to the clinic with complaints of purulent anal discharge, rectal pain, and blood in her stool. After taking a sexual history of the client, the nurse would determine that the client has which sexually transmitted infection?
Gonorrhea. Gonococcal rectal infection may occur in women after anal intercourse. Individuals with rectal gonorrhea may be completely asymptomatic; or conversely, may have severe symptoms with profuse purulent anal discharge, rectal pain, and blood in the stool. Rectal itching, fullness, pressure, and pain also are common symptoms, as is diarrhea. Chlamydia shows few if any symptoms in women. Syphilis is characterized by a primary lesion, the chancre, that appears 5 to 90 days after infection. A symptom of human papillomavirus (HPV) infection, also known as condylomata acuminata or genital warts, is lesions in women most commonly seen in the posterior part of the introitus.
The nurse is teaching a client about the different ways to prevent sexually transmitted infections (STIs). Which instructions about the use of a male condom does the nurse include in the lesson? Select all that apply.
Handle the condom carefully." "Store condoms away from heat." "Use latex or plastic male condoms." "Learn how to apply a male condom." The nurse should tell the client to handle the condom carefully so that it is not damaged by fingernails or any sharp objects. Exposure to heat can damage the condom; therefore it must be stored in a cool, dry place. Latex and plastic condoms are more effective than natural skin condoms in preventing STIs. The nurse should provide explicit instructions on how to apply a condom so that the risk for infection is reduced. Natural skin condoms have small pores that allow for the transmission of STIs. Therefore the nurse should instruct the client to choose latex condoms instead.
A pregnant woman with cystic fibrosis (CF) wants to breastfeed her infant. Which assessments would have to be performed in order to make sure that the breastfeedings were safe and effective? Select all that apply.
Monitor sodium levels in breast milk Monitor total fat levels in breast milk Monitor infant growth pattern Breast milk should be monitored for sodium, total fat levels and chloride levels in order to establish safety. Monitoring of the infant growth pattern would provide evidence that the breastfeeding is adequate. Maternal weight would not have to be monitored with regard to the safety of breastfeeding. Obtaining a urinalysis would not be indicated to verify the safety of breastfeeding.
The primary health care provider requests that the nurse test for proteinuria in a pregnant client. What preliminary examination does the nurse perform before testing for proteinuria in order to get accurate results? Select all that apply.
Presence of blood in the urine Presence of bacteria in the urine Presence of amniotic fluid in the urine. Before testing for the presence of proteinuria in a pregnant client, the nurse collects the urine sample for laboratory assessment to detect the presence of blood, bacteria, or amniotic fluid. These substances may interfere with the diagnostic results, leading to a false report. The presence of sodium and uric acid in the urine may help identify the condition of preeclampsia but does not give a false positive result in the test for protein in the urine.
The nurse is talking to a group of student nurses about the evidence chain of custody. Which statement made by the student nurse indicates a need for further teaching?
The evidence should be handed over to the client's family members. The evidence should never be left unattended with the family or a support person, because there is a chance of tampering. The evidence should be labeled with the examiner's name, client''s name, and date. Proper labeling ensures that proper custody of the evidence is maintained. Whoever handles the evidence should sign when giving and receiving the evidence to indicate that the evidence was not tampered with while under the signer's supervision. Maintaining the chain of custody ensures that the evidence can be used in court.
The nurse is teaching a group of nursing students about intimate partner violence (IPV). Which statement made by the nurse is a myth?
"Being pregnant will protect a woman from being an IPV victim." Pregnancy does not necessarily reduce the risk of intimate partner violence and, in fact, research shows that IPV often increases during pregnancy. In intimate partner violence, the victim often avoids confrontations that might trigger violence. A batterer is not necessarily psychologically ill; a highly successful person also can be a batterer. IPV is not related to family income, although middle- and upper-income families are more likely to hide IPV incidents.
A female client tells the nurse that her male partner prefers not to use condoms during intercourse. The client is worried that if she requests that he use a condom, her partner may be offended, and so she complies with his preference. What does the nurse advise the client?
"Discuss the importance of using condoms at a time when you are not having sex." The nurse needs to tell the client to negotiate with her partner to have protected sex. One way to do this is to speak to the partner at a time when they are not engaged in a sexual activity, which may make it easier to bring up the subject. Telling the client that there will be terrible consequences is not helpful and is not appropriate nursing behavior. Instead the nurse needs to suggest healthy, effective strategies to help the client communicate with her partner. It is dangerous to suggest that the client may have unprotected sex once in awhile, because it may increase the chance of infection. Societal pressure and preconceptions often make it difficult for women to carry condoms and insist that their partners use them, and it may be unrealistic for the nurse to demand such assertiveness.
Which are myths about intimate partner violence (IPV)? Select all that apply.
=Being pregnant protects a woman from IPV. =Only men with psychologic problems abuse women. =Women who experience IPV like to be beaten and deliberately provoke the attack. Myths about intimate partner violence include that being pregnant protects a woman from IPV, only men with psychologic problems abuse women, and women who experience IPV like to be beaten and deliberately provoke the attack. Facts about IPV include that it can occur in any family, one-fourth of all women experience IPV, and 4 percent to 8 percent of all women who experience violence experience it during pregnancy.
Which woman is more likely to seek help for intimate partner violence (IPV)? Select all that apply.
=One who has been beaten frequently and severely. =One whose children have also become victims of violence. Some women are more likely to seek assistance for IPV when compared to others. This group includes women who have been severely abused and those whose children have also become victims of physical violence. A client who has experienced violence for the first time may not seek help. However, a client who has experienced violence frequently is likely to report about IPV. A woman who is dependent on her partner financially or emotionally is less likely to report or seek help for IPV. A client who has witnessed family violence in her family of origin is less likely to experience IPV.
When a nursing instructor is teaching a group of nursing students about the signs of potential male batterers, which characteristics should be mentioned?
A tendency toward jealousy. Though no two male batterers are the same, there are some typical behaviors that many male batters share. A typical male batterer could show a tendency toward jealousy. A male batterer loses his temper easily due to a low, rather than high, tolerance for frustration. Male batterers tend to have low self-esteem, though they may try to mask it. A male batterer may have rigid opinions about proper male and female behaviors and would not disregard traditional gender roles.
Intimate partner violence (IPV) has been linked to many other health problems. Which health problems are included? Select all that apply.
Arthritis Headaches GI problems STIs and pelvic pain Substance abuse and depression. Intimate partner violence (IPV) has been linked to many other health problems, which include headaches, GI (not GU) problems, chronic (not acute) pain, arthritis, STIs, pelvic pain, substance abuse, depression, PTSD, and suicide. Women with any of these symptoms should be carefully assessed.
A client who was sexually assaulted is discharged. Which nursing intervention performed by the student nurse at discharge is inappropriate and needs correction?
Asking the client's friends or family to check up on the client. Following a sexual assault it's important that the nurse help the client to feel in control again. The nurse cannot ask the client's friends or family to follow up with the client, because the client may not be ready to tell her personal contacts about the assault. Instead, the nurse should refer the client to a community agency or rape-awareness group for support and information on preventive strategies, so the client feels safeguarded in the future. A self-defense class may give the client more confidence in preventing or fighting off a future assault. The nurse should inform the client that the client can speak to the primary health care provider if and when the need arises.
What is the most common causative agent of ophthalmia neonatorum?
Chlamydia trachomatis. Ophthalmia neonatorum is a conjunctivitis that occurs in newborns. It is most commonly caused by Chlamydia trachomatis. Therefore, it is most commonly seen in the neonates born to clients with Chlamydial infection. Neisseria gonorrhea causes gonococcal infections. Human papillomavirus causes condylomata acuminate or genital warts, but not ophthalmia neonatorum. Gardnerella and Mobiluncus are the anaerobic bacteria that cause bacterial vaginosis, but not ophthalmia neonatorum.
A client has been sexually assaulted and is receiving an initial evaluation in the Emergency Department. She is concerned that she may become pregnant. Which priority action should the nurse implement to address the client's concern?
Determine the length of time post assault and if it is less than 120 hours, emergency contraception may be provided. It would be most important for the nurse to determine when the assault occurred to interpret this information relative to the pregnancy test results. Although the nurse may want to ask about the LMP, it will not provide evidence of whether or not the client may be pregnant. Even if the pregnancy test is negative, the client may still be pregnant and, as such, further evaluation should be performed. A D&C may prove to be needed, but not at this time.
Which test does the nurse evaluate to understand the cause of fatigue, shortness of breath, and dyspnea in a pregnant client?
Electrocardiography Fatigue, shortness of breath, and dyspnea in a pregnant client indicate primary pulmonary hypertension (PPH). Therefore, the nurse needs to evaluate electrocardiography results, which diagnose the condition. The 24-hour urine collection is used to evaluate total protein excretion and creatinine clearance in a pregnant client with diabetes. The nonstress test is used to assess fetal well-being in a pregnant client with diabetes. The glycosylated hemoglobin test is used to assess glycemic control in a pregnant client with diabetes.
The nurse is preparing a diet plan for a pregnant client with preeclampsia. What does the nurse include in the client's diet? Select all that apply
Food with low sodium content Food with high zinc content Six to eight glasses of water per day Patients with preeclampsia may have edema, which may worsen with excessive salt intake. Therefore, the diet plan of a pregnant client with preeclampsia should include not more than 1.5 gm of sodium per day. The diet plan should also include food with high zinc content to prevent anemia caused by preeclampsia. The patient should drink six to eight 8-ounce glasses (approximately a liter) of water per day to maintain adequate fluid in her body. A pregnant patient should consume fiber-rich food to prevent constipation. The pregnant client with preeclampsia should limit her caffeine intake and should not consume excessive coffee.
What are some characteristics of a potential male batterer? Select all that apply.
Has low self-esteem Has deficits in assertiveness Higher incidence of growing up in an abusive or violent home. Has problems with abandonment, loss, helplessness, dependency, insecurity, and intimacy. Some characteristics of a potential male batterer include low self-esteem; deficits in assertiveness; low (not high) frustration tolerance (loses temper easily, not rarely); higher incidence of growing up in an abusive or violent home; inadequate (not adequate) verbal skills, especially with expressing feelings; and problems with abandonment, loss, helplessness, dependency, insecurity, and intimacy.
Which behavioral symptoms can be seen in the third type of acute phase reaction according to Burgess and Holmstrom? Select all that apply.
Impaired decision-making. disoriented . The third type of acute phase reaction is shocked disbelief or disorientation. According to Burgess and Holmstrom, during the shock disbelief, or disorientation, phase, the client will experience disorientation and difficulty in decisionmaking. The client experiences restlessness and smiles anxiously during the second type of acute phase. The client has a calm demeanor during the controlled emotions phase, which is the first type of acute phase.
What are the characteristics of a male batterer? Select all that apply.
Inability to express feelings Inability to empathize with others Involvement in substance abuse. A potential male batterer is usually unable to express feelings and uses violence as a medium to express feelings. He is unable to empathize with others' feelings and does not feel guilty committing violence. A substance abuser has impaired judgment due to which he may resort to violence. Potential male batterers usually hve low self-esteem and low assertiveness. These characteristics may make them feel frustrated and they may get involved in violence to reduce their frustration.
A non-English speaking immigrant woman shows signs of abuse. Which program would most help the client leave the abusive relationship?
Language education and skills-development classes. Language education and skills-development classes help boost confidence and instill a sense of independence in immigrant women. They help these women understand others and become more independent. Students against violence everywhere (SAVE) is a nationwide pro-peace effort to encourage school children to promote justice. Informational activities for adolescents would encourage the adolescents to discuss sex roles and relationships. Promoting legislation and policies against violent acts is a measure of prevention and advocating against violence.
When teaching self-care prevention of genital tract infections, the nurse should instruct the woman to:
Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath. Clinical observations and research have suggested that tight-fitting clothing, and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue. Prevention of genital tract infections includes reducing dietary sugar and eating yogurt, and choosing underwear or hosiery with a cotton crotch that is absorbent and breathable. Douching can irritate tissue, alter pH, and create an environment conducive to fungal growth.
Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
Mitral valve Prolapse Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension or endocarditis during pregnancy.
What finding in a client indicates a potential risk for complications during the labor process?
Persistent dark red vaginal bleeding. Dark red blood is indicative of an old uterine bleed which was left untreated. It may indicate fetal hypoxia. Therefore, a persistent flow of dark red vaginal bleeding is a sign of a potential complication during the process of labor. A maternal body temperature of 99.7o F is normal and does not indicate any complication. Intrauterine pressure greater than 80 mm Hg is a sign of potential complications. Contractions lasting for more than 90 seconds may increase risk during labor.
During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurse's first response should be to do what?
Reassure the woman that the abuse is not her fault. Of utmost importance for women who disclose that they are experiencing or have experienced IPV (or sexual assault, another hidden trauma) is to validate that they have been heard. It can be demoralizing when, despite the client taking the risk to disclose, the health care provider does not acknowledge the importance of what has just been said. Although all of these responses are appropriate when dealing with an abused woman, the nurse first should validate what the woman has said.
While speaking to a couple about child care, the nurse notices that the female partner has bruises on her forearm. What should the nurse do prior to assessment of intimate partner violence in the female partner?
Request the male partner leave the female partner alone with the nurse briefly. When the nurse suspects that the female partner is a victim of physical abuse, the nurse should always assess the client in complete privacy. It is important that the suspected abuser, in this case the male partner, is absent during the assessment, so that the victim can communicate freely with the nurse. The victim would not be comfortable in discussing her relationship with her husband in front of her. Therefore, the nurse should discuss their relationship with the male and the female partner separately. The nurse should first find out if the female partner is a victim of intimate partner violence and then assess her husband. The nurse should perform a physical examination of the female partner in the absence of the male partner.
A nurse is working with a male coworker who is whistling at her, talking about how pretty she is, and how big her breasts look in her uniform. What type of sexual violence is the nurse receiving from the male coworker?
Sexual harassment. Sexual harassment includes unwelcome, degrading sexual remarks, contact, or behavior such as exhibitionism that makes the work or other environment uncomfortable or difficult. Sexual intimacy is consensual sex between two people. Sexual assault refers to intentional, unwanted, completed or attempted touching of the victim's genitals, anus, groin, or breasts, directly or through clothing as well as by voyeurism. Intimate partner violence is defined by the National Violence Against Women Survey (NVAWS) as "the actual or threatened physical, sexual, psychologic, or emotional abuse by a spouse, ex-spouse, boyfriend, girlfriend, ex-boyfriend, ex-girlfriend, date, or cohabiting partner."
A client is being treated with oral metronidazole (Flagyl) for bacterial vaginosis. After a few days, the client experiences abdominal distress, nausea, vomiting, and headache. What can the nurse conclude from these problems in the client?
The client consumed alcohol with the drug. A client who is on oral metronidazole (Flagyl) will develop abdominal distress, nausea, vomiting, and headache if alcohol is consumed. Having sexual intercourse during the therapy will not have any severe side effects. Allergic reactions would be seen in the form of rash, not as nausea, vomiting, or headache. A sharp, unpleasant metallic taste in the mouth, furry tongue, central nervous system reactions, and urinary tract disturbances are side effects of the drug.
Which statement defines the feminist theory of violence?
The feminist theory of violence looks at victimization through a gender and power lens. Feminist theory gives a view of violence from a feminist perspective. Power and control tactics are central events that lead to violence. The feminist theory explains the role of gender and power in victimization. Social perspective would explain the effect of family dynamics and multigenerational violence transmission. Also, social perspective explains the influence of social beliefs on gender-based behavior and response to a particular behavior. An ecologic model explains the dynamic relation between person and environment.
The nurse advises a postpartum client with hepatitis B virus (HBV) to avoid sharing saliva through kissing or sharing dishes with her partner. However, breastfeeding her infant is encouraged if the client so desires. What could prevent the transmission of the virus to the infant?The infant received prophylaxis at birth.
The infant received prophylaxis at birth. A client with HBV is asked to avoid sharing saliva through kissing or sharing dishes with partners, because there is a risk for transmission of the infection. However, the client can breastfeed if the infant received prophylaxis at birth Newborn HBV prophylaxis will prevent the transmission of infection. The infant will not be on antibiotic therapy, but on an immunization schedule to prevent infection. The virus can be transmitted by breastfeeding if the infant is not given prophylaxis at birth. Vaccination during pregnancy will not help prevent the transfer of infection through breast milk.
While assessing a pregnant client, the nurse advises the client to eat thoroughly cooked meat, wash hands thoroughly with soap and water, and avoid exposure to cat litter. What is the reason for giving this advice?To reduce the risk of toxoplasmosis in the client
To reduce the risk of toxoplasmosis in the client. Toxoplasmosis is protozoal infection that is caused by a parasite Toxoplasma gondii. The disease-causing pathogen is spread by eating raw meat and by exposure to infected cat litter. Therefore, to prevent toxoplasmosis, the nurse would advise the client to eat cooked meat, follow proper handwashing technique, and avoid exposure to cat litter. Cytomegalovirus infection is transmitted by the transplantation of an infected organ, transfusion of infected blood, and sexual contact. Therefore, eating cooked meat will not prevent cytomegalovirus infection in the client. Congenital rubella syndrome is caused in a neonate born to a client with rubella infection. Therefore, maintaining proper hygiene and vaccinating the pet cat will not prevent congenital rubella syndrome in the newborn. A neonate born to a client with cytomegalovirus infection has a risk of splenomegaly and chorioretinitis. Therefore, measures to prevent cytomegalovirus infection will help to reduce the risk of splenomegaly and chorioretinitis in the newborn.
When should the nurse give the emergency contraception to a victim of sexual abuse to prevent pregnancy?
Within 120 hours after intercourse. The emergency contraception should be given to the victim within 120 hours after intercourse in order to prevent the fertilization of the sperm and ovum. Emergency contraceptives will not prevent contraception if taken after the 120-hour window after intercourse.
When does a client develop a viremic influenza-like response after being infected with human immunodeficiency virus (HIV)?
Within 6 to 12 weeks after the virus infects the body. A viremic influenza-like response is most commonly seen in HIV-positive patients. After the virus enters the body, its seroconversion into HIV positive status occurs within 6 to 12 weeks. Therefore, the client would have a viremic influenza-like response within 6 to 12 weeks after the virus enters the body. Antiretroviral therapy helps to destroy HIV and does not worsen the symptoms in the client . Therefore, the client will not have a viremic influenza-like response one year or immediately after initiating antiretroviral medications. The seroconversion of the virus takes place within 6 to 12 weeks; hence the client may not have viremic influenza-like response immediately after the virus enters the body.
The nurse's best measure when evaluating the care of a woman in an abusive situation is based on what?
Woman's declaration of a safety plan. Safety is the most significant part of the intervention. The woman's decision to leave her partner would be a positive step for the woman, but it is not the most significant part of the intervention. In addition, many women choose to return to the relationship. Couples' counseling generally is not recommended. Initially, individual counseling would be more beneficial. Neither would be a measure of success in the evaluation of the care plan of an abused woman. The woman may express her gratitude to the nurse in an effort to end the conversation. This does not indicate the woman's readiness to leave the relationship or to make a plan for safety.
The nurse is assessing a pregnant client with a cardiac disorder. After the assessment, the nurse informs the primary health care provider that the client is symptomatic, with marked limitation of activity. Which class of cardiac disorder does the client have according to the New York Heart Association (NYHA)
class III The New York Heart Association's (NYHA) functional classification of organic heart disease is based on the degree of disability due to cardiac disease in the client. The cardiac diseases that are symptomatic with marked limitation of activity are grouped under class III cardiac diseases.Cardiac diseases grouped under class I are characterized as being asymptomatic without limitation of physical activity.Class II cardiac diseases include symptomatic diseases with slight limitation of activity. Cardiac diseases grouped under class IV are symptomatic and cause an inability to carry out physical activity without discomfort.
The nurse is caring for a client who was drugged and suffered forced oral penetration, although there was no removal of clothing or contact with the patient's genitals. What is the best nursing intervention?
collecting first voiding specimen. Because the client was drugged, it is appropriate to collect the first voided specimen to acquire evidence of drug-facilitated sexual assault. The client had no genital contact, so a speculum exam is not required and would not produce the necessary evidence. The client's vital signs should be checked before removing the clothes, and clothing should be checked for stains and tears. If the client wants to use the toilet, then the client should be instructed to avoid wiping away vaginal secretions, because these could contain evidence as well
The nurse is caring for a postpartum breastfeeding client with asthma who has been prescribed theophylline (Theobid). Which complications does the nurse assess for in the newborn? Select all that apply.
jitteriness cardiac arrhythmias vomiting feeding difficulties Theophylline (Theobid) is prescribed to clients with asthma and is not contraindicated in breastfeeding clients. However, in some sensitive individuals the medication can lead to jitteriness and cardiac arrhythmias in newborns by stimulating the central nervous system (CNS).Theophylline (Theobid) neither reduces sodium content nor impairs vitamin A absorption. Therefore, it does not cause hyponatermia or vitamin A deficiency in the newborn. Theophylline (Theobid) does not impair iron absorption and does not reduce hemoglobin content. Therefore, the newborn would not have Cooley's anemia.
In a variation of rooming-in, called couplet care, the mother and infant share a room and the mother shares the care of the infant with whom?
the nurse . In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room-maternity-care. The father is included in instruction regarding infant care whenever he is present. The grandmother is welcome to stay and take part in the woman's postpartum care, but she is not part of the couplet. An elder sibling may stay with the client and her baby but is not part of the couplet.
Which medication does the nurse expect to find prescribed for a pregnant client who requires anticoagulant therapy for recurrent venous thrombosis?
Enoxaparin Lovenox Enoxaparin (Lovenox) is prescribed for a pregnant client for recurrent venous thrombosis, as it does not cross the placenta and has no teratogenic effects associated with its use. Warfarin (Coumadin) is generally not prescribed, because it causes fetal bone and eye anomalies and cognitive impairment. Terbutaline (Brethine) is not prescribed for pregnant clients, because it may cause tachycardia, irregular pulse, myocardial ischemia, and pulmonary edema. Oxytocin (Pitocin) is administered to induce labor.
The primary health care provider orders magnesium sulfate (Sulfamag) for a pregnant client who is being transported to the tertiary care center. What actions does the nurse follow according to the protocol? Select all that apply.
Mix the drug with a local anesthetic agent. Administer 5 g to each buttock as a loading dose. Administer 5 g as a maintenance dose alternately to each buttock. The nurse should administer the magnesium sulfate (Sulfamag) intramuscularly to a pregnant client who is being transported to the tertiary care center. The medication should be mixed with a local anesthetic to reduce the pain caused by injection. The nurse should administer 5 g of magnesium sulfate (Sulfamag) to each buttock as a loading dose of 10 g total. A maintenance dose of 5 g should be administered alternately to each buttock every 4 hours. The intravenous route is not preferred in clients who are being transported to the tertiary care center. The nurse should not administer the maintenance dose every 8 hours, because it may lead to insufficient action of the medication.
What are some characteristics of women in abusive relationships? Select all that apply.
Poor and uneducated May have fewer problem-solving skills Have fewer resources and support systems Feminine characteristics such as compassion, sympathy, and yielding behavior Financially more dependent on their partner. Some characteristics of women in abusive relationships include being poor and uneducated; having fewer problem-solving skills; having fewer resources and support systems; being financially more dependent on their partners; and having feminine characteristics such as compassion, sympathy, and yielding behavior. Women who are financially independent; with good problem-solving skills; with traits of assertiveness, independence, and willingness to take a stand are usually not in abusive relationships.
The nurse is teaching a pregnant client how to recognize signs of preeclampsia and when to report to the primary health care provider. Which statements by the client indicate effective learning? Select all that apply.
"I should report if I experience blurred vision or headache." "I should report if I feel a decrease in the baby's movements." "I should sit and use my right arm to accurately measure my blood pressure." The pregnant client should report to the primary health care provider if she experiences blurred vision, dizziness, and headache. These are the common clinical signs of preeclampsia. The client should report to the primary health care provider if she observes fewer fetal movements per hour, because it may be indicative of fetal compromise due to preeclampsia. To obtain accurate recordings, the pregnant client should use her right arm while in a sitting position to measure her blood pressure. The pregnant client should report to the primary health care provider in case of decreased urinary output, because a decrease in the glomerular filtration rate leads to degenerative glomerular changes and oliguria. The pregnant client should inform the primary health care provider if a dipstick test shows the value of 1+ or more, because it indicates proteinuria, an important sign of preeclampsia.
During a follow-up assessment of a client who had been a victim of sex trafficking, the nurse suspects that the patient has Stockholm Syndrome. Which client response indicates Stockholm Syndrome?
"I want to see my abuser again. I just want him to know I'm OK." Stockholm Syndrome is a condition in which the client who has been a victim of sex trafficking becomes attached to the enslavers. The victim's desire to see and reassure the abuser indicates that the client is a victim of Stockholm Syndrome. The response that the client will immediately report to the nurse if she is abused ever again indicates that the therapy provided by the nurse is effective. The response that the client feels more confident about sharing her thoughts with others about her experiences indicates that the therapy provided to the client is effective. The client 's response that she would speak to other women and counsel them about self defense against abuse indicates that the client has recovered from the trauma of abuse.
Which sexual practices should be avoided to help prevent the spread of sexually transmitted infections? Select all that apply.
=Oral-anal contact =Unprotected anal intercourse. =Any sex that causes tissue damage or bleeding (fisting, rough vaginal or anal intercourse, rape). Sexual practices that should be avoided to help prevent the spread of sexually transmitted infections include oral-anal contact, unprotected anal intercourse, and any sex that causes tissue damage or bleeding (fisting, rough vaginal or anal intercourse, rape). Sex with one partner, HIV and STI testing, and protected vaginal intercourse are low-risk practices.
A female client is receiving treatment for gonorrhea. What does the nurse tell the client while providing care? Select all that apply.
=Recommend that the client be tested for human immunodeficiency virus (HIV) =Reinforce teaching of correct condom use during sexual activity. =Encourage the client to notify her partners about the infection. There is an increased risk for HIV infection in clients who have gonorrhea. Therefore the nurse needs to counsel the client to seek HIV testing. The nurse needs to instruct the client to use a condom during sexual activities, because there may be a chance of reinfection if preventive measures are not taken. Gonorrhea is a highly communicable disease, so the nurse encourages the client to notify her partners about their exposure to the disease so that they can seek appropriate assessment and treatment. The treatment does not have a poor success rate, but reinfection occurs if the client does not take proper preventive measures. Gonorrhea is a reportable communicable disease, and the nurse needs to inform the client that the case will be reported to the health authorities.
Which characteristics of documentation by the examiner are most helpful and can be useful to women experiencing domestic violence later in court should they choose to press charges or obtain child support, custody, or alimony? Select all that apply.
=Writes clearly. =Sets off the woman's words in quotation marks and uses such phrases as "client states" to indicate information recorded reflected the woman's words. =Takes photographs of the injuries known or believed to have been caused by domestic violence. =Avoids such legalistic phrases as "woman claims" or "woman alleges" that cast doubt about the truth of the statements. =Describes the woman's demeanor, whether she is crying, shaking, angry, calm, laughing, or sad, even if it belies the evidence of abuse. Documentation by the examiner is most helpful and can be useful to women later in court if the examiner writes clearly; sets off the woman's words in quotation marks and uses such phrases as "client states" to indicate information recorded reflected the woman's words; takes photographs of the injuries known or believed to have been caused by domestic violence; avoids such legalistic phrases as "woman claims" or "woman alleges" that cast doubt about the truth of the statements; and describes the woman's demeanor, whether she is crying, shaking, angry, calm, laughing, or sad, even if it belies the evidence of abuse. The examiner does not record the day of the abuse, but records the time and day of the examination and indicates whenever possible how much time has passed since the abuse
A pregnant client comes to the clinic 24 hours after being treated with penicillin for syphilis with a headache, myalgia, and arthralgia. The nurse recognizes that the client is having which reaction?
A Jarisch-Herxheimer reaction. Clients treated for syphilis with penicillin may experience a Jarisch-Herxheimer reaction. This acute febrile reaction is often accompanied by headache, myalgias, and arthralgias that develop within the first 24 hours of treatment. This reaction is not an anaphylactic, a penicillin allergic, or an adverse reaction.
Which clients are most vulnerable to intimate partner violence (IPV)? Select all that apply.
A client who is unemployed A client who does not have any family members A client who believes that the man is the head of the family. Certain characteristics make a woman more vulnerable to IPV. An unemployed woman may be financially dependent on her partner and therefore less likely to defend herself against IPV. A woman who lacks family support is more prone to become a victim of IPV. A woman who believes that man is the head of the family may be more tolerant of abuse. Therefore, an unemployed client, a client who does not have any family members, and a client who believes that the man is the head of the family would most benefit from the nurse's lecture. A woman who earns more than her husband is financially strong and is therefore less likely to be a victim of IPV. A woman who is more assertive and stubborn is less likely to be a victim of IPV.
The nurse is reviewing the physical assessment data of a client in the fourth stage of labor. Which immediate intervention does the nurse provide after reviewing the data?
Assist the client to void spontaneously. A palpable and distended bladder may indicate urinary retention. A distended bladder may lead to fundal atony, increasing the risk of postpartum hemorrhage and bleeding. Perineal pain and drainage is common during postpartum period. The nurse should encourage the client to void spontaneously to help the bladder return to its nonpalpable stage. It also helps to increase the tone of the uterine fundus and makes it firm. Massaging the abdomen helps the uterus to contract. Cleaning the perineum using warm water reduces the client's discomfort and relieves perineal pain. Cleaning vaginal lacerations is not an appropriate intervention, because there are no lacerations reported in this client's data. A nurse assists a client to flex her upper leg on the hip to observe vaginal lacerations, and using warm water is preferred to hot water.
During assessment, the nurse finds that the client has many scars on her back and arms. The nurse also observes that the client seems scared of her husband and appears very timid and helpless. Which syndrome do these findings indicate in the client?
Battered woman syndrome. Battered woman syndrome is caused by deliberate and repeated physical or sexual assault at the hands of an intimate partner. The patient has evidence of past injuries on different sites of the body, and her behavior around her husband is consistent with battered woman syndrome, which develops over time. Stockholm syndrome is seen in clients who become sympathetic to their captors' views and political leanings. There is no evidence of sexual abuse mentioned, so it less likely the client has rape-trauma syndrome. The client's behavior and scarring are not consistent with posttraumatic stress syndrome, which manifests itself in different ways.
A pregnant client has a medical history of bidirectional shunting and elevated pulmonary vascular resistance. What is the best nursing intervention to ensure the client's safety?
Bidirectional shunting and elevated pulmonary vascular resistance are characteristic features of Eisenmenger syndrome. Pregnancy should be avoided in patients with Eisenmenger syndrome. If the client continues with a pregnancy despite the risks, she should be hospitalized and advised to take complete bed rest. Bed rest helps restrict the client's physical activity.Monitoring FHR and fetal activity is a general intervention performed in the cases of all pregnant client. Suggesting that the client do moderate household work may not be helpful, because it may cause stress or lead to complications in the client. Pregnant clients with Eisenmenger syndrome should have a complete restriction of physical activity; therefore, an individualized aerobic exercise plan is not needed.
The nurse is caring for a client with preeclampsia who gave birth by cesarean section. The primary health care provider prescribes a nonsteroidal antiinflammatory pain medication to the client. What parameter does the nurse closely monitor in this client?
Blood pressure . Nonsteroidal antiinflammatory drugs should be used with caution in clients with preeclampsia. Because preeclampsia is associated with hypertension, these medications may have the potential to further increase such clients' blood pressure. Therefore, the nurse should closely monitor the client's blood pressure. White blood cells are unaffected by nonsteroidal antiinflammatory drugs, and monitoring the WBC count is not required. Monitoring the respiratory rate is essential in preeclampsia associated with seizures and is unrelated to the use of nonsteroidal antiinflammatory drugs. The prothrombin time is usually unchanged in preeclampsia and is not a complication of the administration of nonsteroidal antiinflammatory drugs.
The nurse is caring for a pregnant client with an arrhythmia. Which medication would be the safest to administer?
Digoxin Digoxin (Lanoxin) has shown no evidence of producing unfavorable side effects on the fetus. Therefore, the drug can be used to treat an arrhythmia in the client. Limited data are available regarding verapamil (Calan). Therefore, prescribing verapamil (Calan) to the client may not be safe and may cause teratogenic effects. Quinidine (Quinidex) may cause transient neonatal thrombocytopenia and damage to the eighth cranial nerve. There is no evidence that lidocaine (Xylocaine) has unfavorable side effects on the fetus, but high serum levels may cause central nervous system (CNS) depression at birth. Therefore, verapamil (Calan), quinidine (Quinidex), and lidocaine (Xylocaine) should not be prescribed to the client.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include which actions?
Encouraging the woman to try various upright positions, including squatting and standing. Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.
The nurse suspects that a female client may have been abused. Which nursing action is most appropriate in this situation?
Examine the client in her partner's presence. Seeking assistance from a female primary health care provider may help the client feel secure. Therefore, it is appropriate to ask a female primary health care provider to examine the client. The nurse should always provide privacy while examining the client. It helps make the client feel safe. The client is often not comfortable even in the presence of her family and may not answer due to embarrassment. Retaliation may place the client in danger of further abuse from her partner. Hence, the nurse should not give this advice to the client.
The nurse is counselling a client who is at risk for a sexually transmitted infection (STI). What does the nurse include in her STI prevention teaching? Select all that apply.
Explains in detail how STIs are transmitted. Instructs the client on how to use a condom. Explains how to identify physical signs of ST. The nurse explains to the client how STIs are transmitted so that the client is aware of the risks and does not have any misconceptions about the spread of infections. The nurse should instruct the client on how to use a condom to reduce the risk of infection. Many signs of sexually transmitted infection are visibly evident, and clients should be instructed on how to identify them. Vaginal spermicides have been proven ineffective in protecting against STIs such as gonorrhea, chlamydia, and HIV. Oral contraceptive pills are effective in preventing unwanted pregnancy, but not STIs.
Which vaccinations can be used as preventive measures for sexually transmitted infections (STIs)? Select all that apply.
Hepatitis B. Human papillomavirus (HPV). Hepatitis B and human papillomavirus (HPV) vaccines are effective vaccines for preventing the risk of those sexually transmitted infections. The two human papillomavirus (HPV) vaccines are Gardasil and Cervarix, which are given between the ages of 9 and 26 years to prevent cervical precancer and cancer. Pneumococcal conjugate is a vaccine to prevent diseases caused by Streptococcus pneumoniae (pneumococcus). The meningococcal conjugate vaccine is given to prevent meningococcal disease. Pneumococcal polysaccharide is a pneumococcal vaccine.
Appendicitis is more difficult to diagnose during pregnancy because the appendix is where?
High and to the right High and to the right is the correct position of the appendix as pregnancy develops, which makes diagnosis of appendicitis difficult. The appendix is not hidden by the uterus; rather it is pushed upward and to the right from its usual anatomic location.
Chlamydia increases the risk of which infection in clients?
Human immunodeficiency virus (HIV) infection. Chlamydial infection of the cervix causes inflammation, resulting in microscopic cervical ulcerations, and thus may increase the risk of acquiring HIV. Risk of pneumonia is increased in infants born to mothers with chlamydia, but not in the mothers themselves. Condylomatalata are broad, painless, pink-gray, wartlike infectious lesions on the vulva or the anus seen in clients with syphilis. Ophthalmia neonatorum is seen in infants of mothers with gonococcal infections.
Which infection is prevented with the Cervarix and Gardasil vaccines?
Human papillomavirus (HPV. The Cervarix and Gardasil vaccines are recommended for children aged 9 to 26. The vaccines are effective in protecting against human papillomavirus (HPV) infections, which can lead to genital warts and cancers. Bacterial vaginosis (BV) is treated with oral metronidazole (Flagyl); there are not any preventive vaccines for this. Exogenous lactobacillus (found in dairy products or powder, tablet, capsule, or suppository supplements) and garlic have been suggested for prevention and treatment of vulvovaginal candidiasis. Vaccination is not effective in preventing pelvic inflammatory disease (PID). It can be prevented only by practicing risk reduction measures and using barrier methods.
According to the feminist theory, male dominance and coercive control enhance all forms of violence against women. What forms of violence are included? Select all that apply.
Incest Stranger rape Acquaintance rape Intimate partner violence Sexual harassment in the workplace The feminist theory, with the primary theme of male dominance and coercive control, enhances our understanding of all forms of violence against women, including intimate partner violence, stranger and acquaintance rape, incest, and sexual harassment in the workplace. A gender and power perspective is a way to understand the victimization that occurred. Date rape/acquaintance violence is not included in the feminist theory.
The nurse is assisting the primary health care provider during the labor of a client with cardiac disease. Which intervention should the nurse perform to prevent cardiac complications in the client while performing maternal pushing?
Instruct the client to avoid the Valsalva maneuver. The Valsalva maneuver is a moderately forceful exhalation against closed airways. The nurse should instruct the client to avoid performing the Valsalva maneuver when pushing the baby out during the second phase of labor. The maneuver tends to prevent diastolic ventricular filling and obstructs left ventricular flow. Therefore, the Valsalva maneuver should be avoided to prevent obstruction to cardiac filling. Outlet forceps are used to decrease the length of the second stage of labor. Use of stirrups may cause compression of popliteal veins.The side-lying position is preferred during labor in clients with cardiac disease to facilitate uterine perfusion.
The nurse is caring for a client who is a victim of intimate partner abuse. The client avoids interaction with the nurse and does not participate in the group therapy activities. Which action by the nurse will help the client express herself openly and honestly?
Interact with the client individually in a private room When a client avoids interaction and participation in group activities, it may indicate that she feels socially isolated and stigmatized. The nurse should interact with the client in a private room so that she will feel comfortable expressing her feelings and interacting freely. Talking with the client in a calm voice helps to establish a nonthreatening atmosphere, but does not help to reduce social isolation. The nurse refers the client to counseling and social services to provide ongoing support, but not necessarily to prevent social isolation related to stigma. The client may not feel comfortable interacting in the presence of family members. Therefore, allowing the client 's family to spend time with the client may not help to reduce social isolation related to stigma.
The nurse is caring for a client admitted to the emergency department with multiple lacerations; blunt trauma to the head; bruised, swollen eyes; and a stab wound to her right arm. What type of violence has this client suffered?
Intimate partner violence. Intimate partner violence is defined by the National Violence Against Women Survey (NVAWS) as "the actual or threatened physical, sexual, psychologic, or emotional abuse by a spouse, ex-spouse, boyfriend, girlfriend, ex-boyfriend, ex-girlfriend, date, or cohabiting partner." Sexual assault refers to intentional, unwanted, completed or attempted touching of the victim's genitals, anus, groin, or breasts, directly or through clothing as well as by voyeurism. Sexual violence is a broad term that encompasses a wide range of sexual victimization including sexual harassment, sexual assault, and rape. Rape-trauma syndrome occurs when humans experience fear, horror, or helplessness after a life-threatening traumatic event such as rape or combat, and there is an intense initial stress response.
According to the 1992 guidelines by The Joint Commission, emergency departments and ambulatory care departments must have protocols for victims of physical or sexual assault that address which topics? Select all that apply.
Patient consent Evidence collection Photographing injuries. In its 1992 guidelines, The Joint Commission (TJC) required emergency departments and ambulatory care departments to have protocols on physical assault, rape or sexual assault, and domestic abuse. These protocols must address client consent, evidence collection, and photographing injuries. The roles of the many different professionals, including prosecutors and forensic specialists, are identified in the National Protocol for Sexual Assault Medical Forensic Exams, Adults/Adolescents, for the aftercare of sexual trauma victims.
The nurse is reviewing the medical history of a 35-year-old pregnant client. The client is in the first trimester of her second pregnancy. The nurse finds out that the client had twins in the first pregnancy and had congestive heart failure during her second month of the postpartum period. The medical history also indicates that the client has 40% left ventricular ejection fraction. What risk does the nurse expect in the client?
Peripartum cardiomyopathy (PCM) PCM is a type of congestive heart failure associated with reduced functioning of the myocardium. Pregnant clients who are 35 years old or older and have a history of multiple gestation and congestive heart failure during the first five months of the postpartum period are at high risk of PCM. Marfan syndrome is an autosomal genetic disorder that causes aortic dissection and rupture. Mitral regurgitation occurs in clients with Marfan syndrome. Bidirectional shunting is observed in Eisenmenger syndrome.
Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach?
Prepare the woman for an ultrasound and blood work. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Telling the woman that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.
What is the most effective way to reduce the adverse consequences of STIs for women and for society?
Preventing infection (primary prevention). The most effective way of reducing the adverse consequences of STIs for women and for society is preventing infection (primary prevention). Preventing risky drug-related and sexual behaviors, preventing sexually transmitted infections during pregnancy, and getting treatment early for STIs are good, but are not the most effective way of reducing STI consequences.
Which finding in a urine specimen of a pregnant patient indicates the client has proteinuria?
Protein concentration that is greater than 300 mg/24 hours. Proteinuria is determined from dipstick testing on a clean-catch or catheterized urine specimen or evaluation of a 24-hour urine collection. Protein concentration that is greater than 300 mg/24 hours in a 24-hour urine specimen indicates proteinuria. A concentration of greater than or equal to 5 g protein in a 24-hour urine collection will indicate severe preeclampsia. Protein concentration greater than 30 mg/dl in at least two random urine specimens collected at least 6 hours apart will indicate proteinuria. Value of greater than or equal to 1+ on dipstick measurement indicates proteinuria.
The nurse notices that a pregnant client shows signs of fatigue and lethargy, and has glossitis and rough skin. Which condition does the nurse likely suspect?
Signs of fatigue, lethargy, glossitis, and skin roughness indicate megaloblastic anemia. This is caused by a folic acid deficiency. Thalassemia is indicated by severe anemia and congestive heart failure in a pregnant client. Fatigue indicates iron deficiency anemia, but glossitis and skin roughness are not present. Anemia, repeated infections, shortness of breath, fatigue, and jaundice are seen in a patient with sickle cell hemoglobinopathy.
A nursing instructor explains that perpetrators often have a family history of violence. These people may have witnessed numerous incidents of violence while growing up, which makes them more likely to be violent as adults. Which viewpoint best classifies this explanation of violent behavior?
Social perspective. Social perspective explains the role of family influence on a perpetrator's behavior later in life. The perpetrator has turned violent because of the influence of family members who were violent. Biologic factors are neurochemical factors that contribute to violence. The ecologic model explains the effect of violence on the victim's environment. The feminist perspective explains how gender and power influence victimization.
There are multiple theories on why some men rape. What are some of those theories? Select all that apply.
Some perpetrators are conditioned to become aroused to forced sexual violence. Using violent pornography may normalize preexisting sexually aggressive impulses. The men see women as sex objects and view them negatively, with hostility, or as dangerous. Male entitlement to sex. Some theories on why men rape include: some perpetrators are conditioned to become aroused to forced sexual violence; using violent pornography may normalize preexisting sexually aggressive impulses; the men see women as sex objects and view them negatively, with hostility, or as dangerous; and male entitlement to sex. The theories on why men rape do not include that the men see women as sex slaves to their sexual desires, or that the men have seen sexual activity when they were growing up.
The nurse is assessing a client who is 18 weeks pregnant. The client reports heavy bleeding, infection, and excessive cramping. Which treatment strategy should be included in the treatment plan?
Suction curettage Heavy bleeding, infection, and excessive cramping are signs and symptoms of miscarriage. In this situation, fetal or placental tissue must be removed from the uterus by suction curettage. McDonald technique is used in case of cervical insufficiency. In this technique, suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix. MTX is used in the treatment of ectopic pregnancy. Misoprostol (Cytotec) is prostaglandin drug. If bleeding and infection are absent, then misoprostol (Cytotec) is used for miscarriage.
Which is a true statement about TORCH infections?
TORCH infections include toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus. The true statement about TORCH infections is that they include toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus. TORCH infections produce flulike (not pneumonia) symptoms in the mother; TORCH infections do affect the pregnant woman and her fetus; and TORCH infections form a group of organisms capable of crossing the placenta.
The nurse is caring for a victim of sexual assault. The nurse obtains the client's consent, takes photographs, and then informs the police. Thereafter, the nurse seeks the assistance of a sexual assault nurse examiner (SANE). Which action of the nurse may violate the legal process?Taking the client's photograph
Taking the client's photograph. The nurse should collect the victim's photograph after informing the police. If the police permit photographic evidence, then it should be collected. It is necessary to gain the client's consent prior to evidence collection. Therefore, it is the correct procedure. It is necessary to submit the evidence to police, so that proper action is taken against the perpetrator. The nurse should seek the assistance of a SANE, because a SANE has the experience and proper training to assist assault victims.
The nurse is preparing a plan of care for a client who is a victim of intimate partner violence (IPV) using the ABCDES framework. Which intervention given by the nurse would coincide with the E part of the ABCDES framework?
Teaching about the various community resources available for help. In the ABCDES framework, E stands for education. Teaching the client about the various community resources available for help is the intervention to be included in the E part of ABCDES framework. B stands for belief, according to which the nurse should make the client believe that being victimized is not acceptable and is not her fault. C stands for confidentiality, according to which the nurse should provide assurance that the client's information would not be shared with others. A stands for alone, according to which, the nurse should reassure the client that she is not alone and that others have also faced this.
A sexual assault victim contacts the health care facility. The nurse responds in a helpful manner and provides emotional comfort. Further, the nurse helps the client contact the relevant support groups. What is the intended result of this type of intervention?
The client has a reduced risk of posttraumatic stress. The goal of supportive care is to help victims feel safer, less threatened, and less anxious. The nurse is providing proper psychologic first aid, so the client will have a reduced risk of posttraumatic stress. Emotional help and comfort from the nurse help decrease the client's potential for a worsened mental condition. The nurse has provided proper psychologic first aid, so the client will take less time to adapt to normal life. If the nurse has provided proper care, the client will not become reliant on the nurse for emotional care.
The nurse is caring for a victim of rape-trauma syndrome and finds that the client is in shocked disbelief. Which observation helped the nurse draw this conclusion?
The client has difficulty concentrating and has poor recall of the events. A client who is in shocked disbelief would be disoriented and may have a poor recollection of the incident. Therefore, the nurse would observe that the client is unable to concentrate properly and cannot recall the events. The client who has controlled emotions would maintain a calm demeanor and answer the nurse in a matter-of-fact manner. A client who expresses emotions would relive the scene over and consider the things that would have helped in escaping. A client who is able to express emotion may show feelings outwardly by crying sometimes or may be calm at other times.
The nurse is assisting a client during the second phase of labor. Which behavior from the client signifies the active pushing stage of the second phase of labor?
The client is inattentive to the nurse's instructions. There are two phases during the second stage of labor, the latent and the active. The active stage is the pushing stage of labor, in which the client experiences severe pain and tries to push the fetus with all her effort. The client is inattentive to the nurse and directs all her concentration on childbirth. During the active phase of vocalization, the client may scream or swear, because the pain is severe.The client feels fatigued and sleepy during the latent phase, not during the active phase. During the latent phase, the client remains quiet and is concerned with the progress of the labor.
The nurse is caring for a client who has vaginal bruising. During documentation, her male partner answers all of the questions for the client and the couple are unable to show appropriate documentation of citizenship for the patient. Of what problem could these findings be a sign?The client may be a victim of sex trafficking
The client may be a victim of sex trafficking. The client shows signs of abuse and lacks the appropriate documentation of citizenship, so there is a chance that the client might have been kidnapped, though further questioning would be needed to be sure. Hence, the nurse would understand that this may be a case of sex trafficking. Even if the client is economically unprivileged, the client would still have the documentation of citizenship. In domestic violence, the client would have documentation of citizenship. In intimate partner violence, the client would not lack citizenship documentation.
The nurse is assessing a victim of sex trafficking. The nurse suspects that the client has Stockholm syndrome. Which finding would help the health care team determine whether the client is a possible victim of Stockholm syndrome?
The client shows empathy with the abuser. In Stockholm syndrome, the client tries to defend the abuser. When the client empathizes with the abuser, the nurse suspects that the client has Stockholm syndrome. Bruises on the arms may be due to any injury; they do not indicate Stockholm syndrome. Severe depression is seen in many assaulted clients and is not a unique characteristic of Stockholm syndrome. Any assaulted client may feel guilty and fearful and refuse to talk about the abuse.
Which behavior can the nurse observe in a victim of sexual abuse during the outward adjustment phase?
The client tries to return to her job and denies her feelings. The outward adjustment phase is the second phase of rape trauma. During this phase, the client resolves her crisis and tries to return to her job. However, the client denies and suppresses her thoughts and feelings. During the disorganization phase the client is in shock and denial, and may feel unclean and want to bathe and douche. Disorientation is the third type of reaction seen in the client during the acute phase. In this phase, the client has difficulty concentrating or making decisions. The client discloses personal thoughts and feelings to the nurse in the reorganization phase.
The nurse is assessing a pregnant client with genital herpes simplex virus (HSV) infection, who is having labor pains. The nurse finds that the client was prescribed antiviral medications. Which assessment finding will determine that a vaginal birth is possible?
Visible lesions are not present at onset of labor. If visible lesions are not present at the onset of labor, then the client may be able to deliver vaginally. The presence of lesions increases the chances of HSV transmission to the neonate and therefore a caesarean birth is recommended. A rapidly progressing labor is a concern only in the presence of lesions, due to the risk of newborn HSV transmission. Neonatal HSV infection usually occurs during delivery, not congenitally. Antiviral medication use does not play a part in determining the possibility of vaginal birth. Antiviral medications help reduce the symptoms of HSV but do not cure the infection.
A client reports yellowish, frothy, and malodorous vaginal discharge. During the assessment the nurse observes strawberry spots in the cervix and inflammation of the vaginal walls and cervix. What will the nurse suggest that the client do in order to provide effective treatment?
Your partner should also receive treatment for the infection. The presence of yellowish, frothy, and malodorous vaginal discharge, strawberry spots, and inflammation of the vaginal walls and cervix indicates that the client has trichomoniasis. The client's partner harbors the infection-causing agent, Trichomonas, in the urethra and prostate. If the client's partner does not receive treatment, the infection may reoccur in the client. Therefore, the nurse informs the client that her partner should also receive treatment in order to prevent reoccurrence. Colloidal oatmeal powder helps to reduce irritation and provides comfort to a client with candidiasis. The nurse will not suggest that the client avoid eating raw eggs and foods rich in carbohydrates, because they do not worsen the patient's condition. The nurse would suggest that the client take metronidazole (Flagyl) orally once a day to prevent adverse effects and drug toxicity.
The student nurse is helping a nurse care for a sexually assaulted client. Which nursing action by the student indicates the need for further teaching?
nstructs the client to return to the hospital the next day to be tested for sexually transmitted infections (STIs) During discharge the client should be instructed to visit any convenient facility for STD testing, but this would be done within 1 to 2 weeks rather than the next day, because the next day would be too soon to detect an STD. The nurse should provide printed instructions for medication at the time of discharge, because there is chance that the client may not remember the instructions. The nurse should ensure that the client is provided transportation to the client's residence. Patients who were sexually assaulted may be angry, fearful, or guilty. The nurse can reassure clients that they are not alone and these feelings are normal.
The nurse finds that a client in labor has developed spontaneous bruises over the skin. The fetal heart activity monitor indicates late decelerations in the fetal heart rate (FHR). What is the best intervention to prevent fetal complications, if the nurse suspects disseminated intravascular coagulation (DIC) in the client?
o2 by mask . DIC may be caused secondary to placental abruption, which may result in late deceleration of the FHR. Late deceleration is due to decreased blood flow and oxygen to the fetus during the uterine contractions (UCs). Therefore, an oxygen mask is applied to the client. A side-lying tilt would provide proper blood flow by decreasing the pressure on the uterus. Hence, the client should be assisted to a side-lying position and not to a supine position. An IV oxytocin infusion is given to increase the UCs during labor, but it is discontinued when a late deceleration is noted. IV fluids are administered to the client to promote fluid balance, but it may not directly help in improving the fetal heart rate.
