Nokea
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.
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A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.
- A. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
- B. Initiate an incident report.
- C. Assess the client's current status.
- D. Notify the physician of the incident.
Correct Answer: C,A,D,B
Rationale: Assess the client first, correct the error, notify the physician, and then document the incident.
On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the physician immediately because of the possibility of:
- A. Ectopic pregnancy.
- B. Abruptio placentae.
- C. Gestational trophoblastic disease.
- D. Complete abortion.
Correct Answer: A
Rationale: Severe pain and hypotension suggest ectopic pregnancy.
A client asks about the benefits of the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. It can reduce menstrual bleeding over time.
- B. It provides protection against HIV.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with irregular periods.
Correct Answer: A
Rationale: The hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against HIV, lasts 3-7 years, and is suitable for irregular periods.
The nurse is catheterizing a client who cannot void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the client asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from first to last.
- A. Document incident.
- B. Clean Betadine from client's vaginal area.
- C. Notify physician ordering catheterization.
- D. Ask client what her reaction is when exposed to Betadine.
- E. File an incident report.
Correct Answer: B,D,C,A,E
Rationale: First, clean the Betadine to stop the reaction, ask about the reaction to assess severity, notify the physician, document the incident, and file an incident report.
The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.