Nokea
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.
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The nurse is caring for a client with a history of glaucoma who is receiving timolol (Timoptic) eye drops. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel a burning sensation when I use the drops.
- B. My heart rate feels slower than usual.
- C. I have a headache in the morning.
- D. My eyes are watery sometimes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, and a slower heart rate is concerning, requiring evaluation to prevent cardiovascular complications. Options A, C, and D are less urgent: burning is common, headaches are nonspecific, and watery eyes are not significant.
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.
A client presents with confusion, mood lability, impaired communication, and lethargy.
The nurse should question which of the following orders?
- A. Dexamethasone suppression Test .
- B. Thyroid studies.
- C. Drug toxicology screen.
- D. Trendelenburg Test .
Correct Answer: D
Rationale: Strategy: Think about each Test . (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct-Test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation