Nokea
Select the 5 actions the nurse should take.
- A. Increase the flow rate of the maintenance IV fluid.
- B. Have the charge nurse notify the provider.
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix.
- F. Administer oxygen at 10 L/min Via nonrebreather face mask
Correct Answer: A,B,C,D,E
Rationale: Correct Answer: A, B, C, D, E
Rationale:
A: Increasing IV fluid flow rate helps maintain hydration and blood pressure.
B: Notifying the provider ensures timely medical intervention and documentation.
C: Placing the client in Trendelenburg position helps improve placental perfusion.
D: Exerting upward pressure on presenting part can alleviate pressure on the cord.
E: Attempting to push the umbilical cord back can prevent cord compression and fetal distress.
Summary:
F: Administering oxygen may be beneficial but not among the immediate actions required.
G: No information provided about this choice.
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The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
The nurse should first notify the provider about------- followed by the-----------
- A. the fetal station and presentation
- B. frequency of uterine contractions
- C. green color of amniotic fluid
- D. history of gestational diabetes
- E. cervical dilation of 4 cm
Correct Answer: C
Rationale: The green color of amniotic fluid indicates meconium-stained fluid which can be a sign of fetal distress.
Which of the following statements should the nurse make?
- A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
- B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
- C. Ensure that the condom fits snugly over the tip of the penis
- D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A
Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
- A. Uneven shoulder and pelvic heights
- B. Symmetrical scapulae
- C. Equal leg lengths
- D. Straight spinal alignment
Correct Answer: A
Rationale: The correct answer is A. Uneven shoulder and pelvic heights are indicative of scoliosis due to the lateral curvature of the spine. Symmetrical scapulae, equal leg lengths, and straight spinal alignment are not typical signs of scoliosis. Symmetrical scapulae and equal leg lengths suggest normal alignment, while straight spinal alignment does not reflect the characteristic curvature seen in scoliosis cases. Therefore, identifying uneven shoulder and pelvic heights is crucial in recognizing scoliosis.