Nokea
A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose?
- A. Vitamin K.
- B. Protamine.
- C. Vitamin E.
- D. Mannitol.
Correct Answer: B
Rationale: Protamine reverses heparin effects.
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A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe?
- A. Suction the nostrils before suctioning the mouth.
- B. Make sure to suction the back of the throat.
- C. Insert the syringe before compressing the bulb.
- D. Dispose of the drainage in a tissue or a cloth.
Correct Answer: A
Rationale: Suctioning the nostrils first clears airways effectively.
A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective?
- A. Blood pressure 120/80.
- B. Pulse rate 80 bpm and regular.
- C. Fundus firm at umbilicus.
- D. Increase in prothrombin time.
Correct Answer: C
Rationale: Methergine causes uterine contraction.
The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
- A. Pulse rate of 50
- B. Temperature of 38C (100.4F)
- C. Firm fundus, but excessive lochia
- D. Lightheaded when moving from a lying to standing position
Correct Answer: A
Rationale: Correct Answer: A - Pulse rate of 50
Rationale:
1. A normal postpartum pulse rate is 60-100 bpm.
2. A pulse rate of 50 is below normal range, indicating potential bradycardia.
3. Bradycardia can be a sign of postpartum hemorrhage or other complications.
4. Reporting this finding promptly can help in early intervention.
Summary:
B: A temperature of 38C (100.4F) could indicate infection but is within normal postpartum range.
C: A firm fundus with excessive lochia may indicate uterine atony, but is not as urgent as bradycardia.
D: Feeling lightheaded when changing positions is common postpartum but not as concerning as a low pulse rate.
A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment?
- A. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child.
- B. Make sure that their son is supervised at all times when the baby is brought home
- C. Include the son in helping to take care of the baby and reinforce the label of “big brother” as a special role.
- D. Observe the son’s reaction to the baby and let him decide when he wants to be
Correct Answer: C
Rationale: The correct answer is C because involving the 2-year-old son in caring for the new baby and reinforcing his role as a "big brother" can help facilitate sibling attachment. This intervention promotes bonding, fosters a sense of responsibility, and helps the son feel included in the family dynamic. It also allows the son to feel special in his new role, leading to positive feelings towards the new baby.
Choice A is incorrect as just spending individual time with the son may not address his concerns about the new baby and could potentially reinforce any feelings of displacement. Choice B is incorrect as constant supervision may not necessarily facilitate sibling attachment and could lead to feelings of restriction or resentment. Choice D is incorrect as it puts the onus solely on the son without providing clear guidance or support in navigating the new family dynamic.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.