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A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Assist the client to breathe into a paper bag.
- C. Have the client tuck her chin to her chest.
- D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Correct Answer: A
Rationale: The client is exhibiting signs of hyperventilation, which can occur as a result of rapid breathing techniques such as pattern-paced breathing during labor. Administering oxygen via nasal cannula can help the client rebalance her oxygen and carbon dioxide levels, which will alleviate the lightheadedness and tingling sensations she is experiencing. Oxygen therapy is the appropriate intervention for respiratory alkalosis caused by hyperventilation. Assisting the client to breathe into a paper bag or instructing her to increase her respiratory rate would exacerbate the hyperventilation and should be avoided. Tucking her chin to her chest is not an appropriate intervention in this situation.
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A woman is being treated for preterm labor with magnesium
- A. The nurse is concerned that the patient is experiencing early drug toxicity. Which assessment finding by the nurse indicates early toxicity?
- B. Patellar reflexes are weak and absent
- C. RR 16
- D. Fetal HR 120
Correct Answer: E
Rationale: The correct assessment finding that indicates early toxicity related to magnesium sulfate administration is the patient complaining of feeling flushed and warm. These symptoms could indicate that the patient is experiencing magnesium toxicity, which can lead to vasodilation and hypotension. Other signs of magnesium toxicity include decreased deep tendon reflexes, respiratory depression, and loss of consciousness. It's essential for the nurse to recognize these early signs of toxicity and intervene promptly to prevent further complications.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
The nurse is providing education on a medical abortion. How would she describe the action of the medications?
- A. Medications thicken the lining of the uterus and decrease uterine contractions.
- B. Medications stop the fetal heart and induce contractions.
- C. Medications soften the cervix, cause uterine lining necrosis, and induce contractions.
- D. Medications thicken the cervix and the uterine lining.
Correct Answer: C
Rationale: Medications used in a medical abortion typically consist of a combination of Mifepristone and Misoprostol. The action of these medications involves three main effects: softening the cervix to facilitate the expulsion of the pregnancy tissue, causing necrosis of the uterine lining to disrupt the pregnancy, and inducing contractions to expel the contents of the uterus. This process is different from a surgical abortion, which involves a procedure to remove the pregnancy tissue from the uterus.
On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.