Nokea
A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr.
- B. Montevideo units constantly at 300 mm Hg.
- C. FHR pattern showing absent variability.
- D. Contractions occurring every 5 minutes and lasting 30 seconds.
Correct Answer: B
Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.
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A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?
- A. Chest pain
- B. Muscle spasms
- C. Cool, moist skin
- D. Incisional pain
Correct Answer: A
Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.
While teaching a newly hired nurse about varicella, a nurse in a pediatric clinic should include which of the following information?
- A. Children who have varicella are contagious until vesicles are crusted.
- B. Children who have varicella should receive the varicella (chickenpox) vaccine.
- C. Children who have varicella should be placed in airborne precautions.
- D. Children who have varicella are contagious 1-2 days before the rash appears.
Correct Answer: A
Rationale: Children with varicella (chickenpox) are contagious until all vesicles are crusted over. The contagious period starts 1-2 days before the rash appears and continues until all lesions are dried and crusted. It is important to educate healthcare providers about the contagious period to prevent the spread of the virus to susceptible individuals.
When teaching about electrical fire prevention at a community health fair, which of the following information should be included?
- A. Use three-pronged grounded plugs.
- B. Cover extension cords with a rug.
- C. Check for tingling sensations around the cord to ensure electricity is working.
- D. Remove the plug from the socket by pulling the plug, not the cord.
Correct Answer: A
Rationale: The correct answer is to use three-pronged grounded plugs because they are safer and reduce the risk of electrical fires. Option B is incorrect as covering extension cords with a rug can pose a fire hazard. Option C is incorrect; tingling sensations around a cord indicate an electrical issue, not proper functioning. Option D is unsafe; plugs should be removed from the socket by pulling the plug, not the cord, to prevent damage and reduce the risk of electrical hazards.
A client with fibromyalgia requests pain medication. Which of the following medications should the nurse administer?
- A. Pregabalin
- B. Lorazepam
- C. Colchicine
- D. Codeine
Correct Answer: A
Rationale: Pregabalin is commonly used to manage pain associated with fibromyalgia. It works by reducing the number of pain signals sent out by damaged nerves. Lorazepam is a benzodiazepine used for anxiety, not pain management. Colchicine is primarily used for gout treatment, and codeine, while an analgesic, is not typically the first-line choice for fibromyalgia pain due to its potential for side effects and misuse.
A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
- A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
- B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
- C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
- D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration
Correct Answer: D
Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.