Nokea
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
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A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?
- A. The first baby should not be affected.
- B. She will need to get treatment after the second baby is born.
- C. There is nothing that can be done to prevent the baby from developing erythroblastosis fetalis, but it can be treated.
- D. She can have intrauterine transfusion for the first baby if blood levels indicate that the child is affected.
Correct Answer: A
Rationale: The first Rh-positive baby is typically unaffected as maternal antibodies develop post-delivery. RhoGAM is given after birth to prevent issues in future pregnancies, not after the second baby.
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.
The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin
- B. Hypernatremia
- C. High serum creatinine
- D. Hyperkalemia
Correct Answer: A
Rationale: Low hemoglobin. Hemodialysis corrects electrolyte imbalances but does not improve anemia.
A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?
- A. Crackers and cheddar cheese
- B. Hard-boiled egg with tomatoes
- C. Steamed fish and potatoes
- D. Tortilla chips with avocado dip
Correct Answer: C
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (A) to prevent hypertensive crisis. Fish and potatoes (C) are safe and nutritious. Eggs (B) and avocado (D) are safe but less balanced.