Nokea
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
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A nurse is caring for a 4-year-old child who is prescribed an intravenous medication preoperatively. Which of the following therapeutic play techniques is most appropriate when reinforcing the teaching for this procedure?
- A. Role play with another nurse the technique of IV placement and how the medication is infused.
- B. Read a story that explains the basics of how IVs are placed.
- C. Watch a movie narrated by nurses and children about IV placement.
- D. Explain the basic procedure and give the child IV supplies to play with minus the needle.
Correct Answer: D
Rationale: The correct answer is D because explaining the basic procedure and providing the child with IV supplies to play with (minus the needle) allows the child to familiarize themselves with the equipment in a non-threatening manner. This technique helps reduce anxiety and fear associated with the procedure. Role-playing may not be suitable for all children as it can be too abstract for a 4-year-old. Reading a story may not provide the hands-on experience needed to understand the procedure. Watching a movie may not be interactive enough for the child to actively engage in the learning process. Providing IV supplies for play is the most appropriate therapeutic play technique for a 4-year-old to prepare them for the IV placement procedure.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers.
- A. "Have syrup of ipecac available in the home."'
- B. "Explain to preschool children that plants can be eaten only after they are cooked."'
- C. "Keep labels on containers of toxic substances and never remove them."'
- D. "Place medications in a cabinet above the sink."'
Correct Answer: C
Rationale: The correct answer is C. Keeping labels on containers of toxic substances is crucial as it provides important information about the contents and hazards. Removing labels can lead to confusion and accidental ingestion. Syrup of ipecac (choice A) is no longer recommended for poisoning treatment. Teaching children to eat cooked plants (choice B) does not address the issue of accidental poisoning. Placing medications above the sink (choice D) may still be accessible to preschoolers.
A nurse is caring for a 23-month-old child with iron-deficiency anemia.
- A. "Give the oral iron supplementation with a glass of cow's milk to prevent stomach problems."'
- B. "Provide diet instructions including limiting citrus fruits in favor of more vegetables."'
- C. "Provide information about complications of iron including gastrointestinal bleeding and ulcers."'
- D. "Give liquid iron through a straw placed in the back of the mouth."'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Iron supplements can stain teeth, so giving liquid iron through a straw placed in the back of the mouth minimizes contact with teeth.
2. This method also helps reduce the risk of tooth decay and enamel erosion.
3. Providing iron through a straw allows for better absorption through the bloodstream.
4. It is important to maximize iron absorption in children with iron-deficiency anemia.
Summary of other choices:
A. Giving iron supplementation with cow's milk can reduce iron absorption due to calcium interference.
B. Diet instructions should focus on iron-rich foods, not just limiting citrus fruits.
C. While complications of iron deficiency should be discussed, this choice does not address treatment.
If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?
- A. Metformin (Glucophage)
- B. Glucagon
- C. Insulin
- D. Glyburide (DiaBeta)
Correct Answer: C
Rationale: The correct answer is C: Insulin. Insulin is the preferred medication for managing gestational diabetes as it is safe for the fetus and provides precise blood sugar control. Metformin (A) and Glyburide (D) are alternatives if insulin is not tolerated, but they may cross the placenta and have potential risks. Glucagon (B) is not used for diabetes management but for treating severe hypoglycemia.
A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and the nurse is immobilizing the infant's arms and legs. Which assessment takes priority during the procedure?
- A. Circulation checks of the lower extremities
- B. Heart rate and crying pattern
- C. Chest expansion and diaphragm excursion
- D. Clarity of spinal fluid and level of consciousness
Correct Answer: C
Rationale: Chest expansion is critical due to the infant's position, which may limit breathing.