Nokea
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:
- A. Assess the fetal heart tones
- B. Check for cervical dilation
- C. Check for firmness of the uterus
- D. Obtain a detailed history
Correct Answer: A
Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.
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The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
- A. Evaluation process
- B. Objective information
- C. Subjective information
- D. Complaining
Correct Answer: C
Rationale: Subjective information is provided by a person.
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Myopia
- D. Amblyopia
Correct Answer: C
Rationale: Visual images are blurred and distorted. Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. These symptoms are classic for myopia. Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Increase the dosage by 2 mU/min increments at 15-minute intervals
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
- D. Question the order
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?
- A. Obtaining blood pressures every two hours
- B. Administering pain medication every three hours as ordered
- C. Monitoring arterial blood gas results
- D. Administering IV fluids at ordered rate of 200 mL/hr
Correct Answer: D
Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (A), pain medication (B), and ABGs (C) are supportive but less directly preventive.
A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?
- A. "Apply the drops directly to the cornea."
- B. "Press the inner corner of the eye after instilling drops."
- C. "Use the drops only when you have eye pain."
- D. "Store the drops in the refrigerator."
Correct Answer: B
Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (A) is incorrect, pain-based use (C) is wrong, and refrigeration (D) is unnecessary.