Nokea
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
- A. Contractions every 2 minutes, lasting 100 seconds
- B. Fetal heart decelerations during a contraction
- C. Beat-to-beat variability between contractions
- D. Fetal heart decelerations at the beginning of contractions
Correct Answer: A
Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.
You may also like to solve these questions
The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position?
- A. Fowlers
- B. Right side lying
- C. Left side lying
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down) is used when removing a PICC line to reduce the risk of air embolism by increasing venous pressure. Fowler’s, right, or left side-lying positions do not provide this protection.
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
- A. Pain in his legs when he walks
- B. Thirst, weight loss, and polyuria
- C. Drowsiness and lethargy after his activities
- D. Weight gain, edema in his lower extremities, and shortness of breath
Correct Answer: D
Rationale: Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.
The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?
- A. Mosquitoes
- B. Blood transfusions
- C. Transplanted organs
- D. Birds
- E. Horses
Correct Answer: A, B, C
Rationale: West Nile virus is transmitted by mosquitoes (A), blood transfusions (B), and organ transplants (C). Birds (D) and horses (E) are hosts but not direct vectors to humans.
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
- A. Normal involution
- B. A full bladder
- C. An infection pain
- D. A hemorrhage
Correct Answer: B
Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.
The physician has prescribed Zyvox (linezolid) for a patient with VRE. The concurrent use of which medication may result in serotonin syndrome?
- A. Nexium (esomeprazole)
- B. Zoloft (sertraline)
- C. Lipitor (atorvastatin)
- D. Zyrtec (cetirizine)
Correct Answer: B
Rationale: Linezolid, a monoamine oxidase inhibitor, can cause serotonin syndrome when combined with SSRIs like Zoloft (sertraline), due to excessive serotonin accumulation. Nexium, Lipitor, and Zyrtec do not interact in this way.