A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
Answer(s): A
(A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants. Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
Answer(s): C
(A) Denial is the disowning of consciously intolerable thoughts. (B) Displacement is the referring of a feeling or emotion from one person, object, or idea to another. (C) Regression is returning to an earlier stage of development. (D) Projection is attributing one's own thoughts, feelings, or impulses to another person.
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