Nokea
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.
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A nurse is caring for newborn who is 1 hr. old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: C
Rationale: The correct action is to reposition the newborn. The vital signs provided indicate that the newborn may be experiencing cold stress, which can lead to hypothermia. Repositioning the newborn can help conserve heat and maintain a stable temperature. Giving a warm bath (choice A) may further decrease body temperature. Applying a cap (choice B) may help retain heat but does not address the underlying issue. Obtaining an oxygen saturation level (choice D) is not necessary based on the information provided.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. "Mongolian spots can be found on the skin of many newborns."
- B. "A caput succedaneum occurs due to compression of blood vessels."
- C. "This is a cephalhematoma, which can occur spontaneously."
- D. "This is erythema toxicum, which is a transient condition."
Correct Answer: C
Rationale: The correct answer is C: "This is a cephalhematoma, which can occur spontaneously."
1. Cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines and is due to trauma during delivery.
2. Caput succedaneum (choice B) occurs due to pressure during labor and resolves within a few days.
3. Mongolian spots (choice A) are benign bluish-grey birthmarks commonly found in newborns and are not related to head swelling.
4. Erythema toxicum (choice D) is a common rash in newborns, not related to head swelling.
In summary, the correct choice is C because it accurately describes the condition observed in the newborn after vacuum-assisted delivery.
Which nursing intervention can help prevent postpartum depression?
- A. Provide printed educational material
- B. Encourage the mother to join a support group
- C. Assess the mother for risk factors of depression
- D. Administer antidepressants as prescribed
Correct Answer: B
Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.
A client at 39 weeks' gestation reports sudden gush of fluid. What is the nurse's priority action?
- A. Perform a sterile vaginal exam.
- B. Assess fetal heart rate.
- C. Check maternal vital signs.
- D. Administer IV fluids.
Correct Answer: B
Rationale: The correct answer is B: Assess fetal heart rate. The priority action in this situation is to assess the well-being of the fetus since the client reported a sudden gush of fluid, which could indicate rupture of membranes. Assessing the fetal heart rate helps determine if the fetus is experiencing distress. Performing a sterile vaginal exam (A) can introduce infection and is not the priority. Checking maternal vital signs (C) can be done after assessing the fetal well-being. Administering IV fluids (D) is not the priority until the fetal status is determined.
The nurse is caring for a postpartum client with excessive bleeding. What is the priority nursing intervention?
- A. Administer IV fluids.
- B. Massage the uterine fundus.
- C. Notify the healthcare provider.
- D. Check the client's vital signs.
Correct Answer: B
Rationale: The correct answer is B: Massage the uterine fundus. This is the priority intervention because excessive bleeding postpartum may indicate uterine atony, which can lead to hemorrhage. Massaging the uterine fundus helps to stimulate uterine contractions and control bleeding. Administering IV fluids (A) can be important, but controlling bleeding takes precedence. Notifying the healthcare provider (C) can be done after implementing immediate interventions. Checking vital signs (D) is important, but addressing the underlying cause of bleeding is the priority.