Nokea
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
- A. Transition labor with contractions every 2 minutes, lasting 90 seconds each
- B. Early labor with contractions every 5 minutes, lasting 40 seconds each
- C. Active labor with contractions every 31 minutes, lasting 60 seconds each
- D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Correct Answer: A
Rationale: Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued.
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Which patient would require additional calories and nutrients?
- A. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
- B. An 18-year-old female who delivered a 7-lb baby and is bottle feeding
- C. A 23-year-old female who had a cesarean birth and is bottle feeding
- D. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
Correct Answer: D
Rationale: The correct answer is D because breastfeeding requires additional calories and nutrients to support the mother's milk production and maintain her own health. Breastfeeding burns extra calories, so the mother needs to consume more to meet her body's needs. Additionally, breastfeeding mothers need to ensure they are getting enough nutrients like calcium, iron, and protein to support their own health and the production of nutritious breast milk for their baby.
Choice A is incorrect because the patient is in her first trimester of pregnancy, not breastfeeding. Choice B is incorrect because bottle feeding does not require as many additional calories and nutrients as breastfeeding. Choice C is incorrect because although the patient had a cesarean birth, the method of feeding (bottle feeding) does not require as much additional nutrition as breastfeeding.
A medical-surgical nurse is asked to float to a women's health unit to care for patients who are scheduled for therapeutic abortions. The nurse refuses to accept this assignment and expresses her personal beliefs as being incongruent with this medical practice. The nursing supervisor states that the unit is short-staffed and the nurse is familiar with caring for postoperative patients. In consideration of legal and ethical practices, can the nursing supervisor enforce this assignment?
- A. The staff nurse has the responsibility of accepting any assignment that is made while working for a healthcare facility.
- B. Because the unit is short-staffed, the staff nurse should accept the assignment to provide care.
- C. The staff nurse has expressed a legitimate concern based on his or her feelings; the nursing supervisor does not have the authority to enforce this assignment.
- D. The nursing supervisor should emphasize that this assignment requires care of a surgical patient for which the staff nurse is adequately trained.
Correct Answer: C
Rationale: The Nurse Practice Act allows nurses to refuse assignments involving practices opposed to their religious, cultural, ethical, or moral values.
The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement?
- A. Discuss the need for medication to treat curl-like oral patches
- B. Suggest switching the infant's formula
- C. Assess the baby's blood glucose level
- D. Remind mother not put the baby to bed with a propped bottle
Correct Answer: A
Rationale: White patches suggest thrush, which requires antifungal treatment (A).
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Uterus soft
- B. Contraction duration of 100 seconds
- C. Four contractions in 10 minutes
- D. Early deceleration of fetal heart rate
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (B) can compromise fetal oxygenation and require discontinuing oxytocin.
A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
- A. There is stratification of communication in a directed manner between nursing staff and administration.
- B. There is increased job satisfaction of nurses, with a lower staff turnover rate.
- C. Physicians are certified in their respective specialty areas.
- D. All nurses have baccalaureate degrees and certification in their clinical specialty area.
Correct Answer: B
Rationale: Magnet status hospitals demonstrate higher nurse job satisfaction and lower turnover rates, along with improved quality of care.