Nokea
A 24-hour-old, full-term neonate is showing signs and possible signs. The nurse is assisting the physician with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.
- A. Administer the I.V. antibiotic.
- B. Hold the neonate steady in the correct position.
- C. Ensure a patent airway.
- D. Maintain a sterile field.
- E. Obtain a serum glucose level.
Correct Answer: B,C,D
Rationale: Holding the neonate steady, ensuring a patent airway, and maintaining a sterile field are critical during a lumbar puncture to ensure safety and procedure success.
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A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
A client asks about the side effects of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. Nausea and breast tenderness may occur.
- B. It causes permanent infertility.
- C. It requires surgical insertion.
- D. It guarantees regular periods.
Correct Answer: A
Rationale: Nausea and breast tenderness are possible side effects of the vaginal contraceptive ring, especially initially. It does not cause permanent infertility, require surgical insertion, or guarantee regular periods.
A client is considering the withdrawal method. Which of the following statements by the nurse is accurate?
- A. The withdrawal method is highly effective with perfect use.
- B. The withdrawal method has a high failure rate and does not protect against STIs.
- C. The withdrawal method requires a prescription.
- D. The withdrawal method is more effective than oral contraceptives.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate and timing issues and does not protect against STIs. It does not require a prescription and is less effective than oral contraceptives.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation(DIC)?
- A. Ringer's lactate solution.
- B. Fresh frozen platelets.
- C. 5% dextrose solution.
- D. Warfarin sodium(Coumadin).
Correct Answer: B
Rationale: Fresh frozen platelets are used to manage bleeding in DIC.