Nokea
A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?
- A. Early deceleration pattern.
- B. Sinusoidal pattern.
- C. Variable deceleration pattern.
- D. Late deceleration pattern.
Correct Answer: B
Rationale: Rh sensitization with fetal hydrops and anemia often causes a sinusoidal fetal heart rate pattern due to severe fetal anemia and hypoxia. Early, variable, or late decelerations are less specific to this condition.
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A post-term neonate diagnosed with persistent pulmonary hypertension is prescribed intravenous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for?
- A. Feeding behaviors.
- B. Temperature.
- C. Skin color.
- D. Blood pressure.
Correct Answer: D
Rationale: Tolazoline is a vasodilator, and monitoring blood pressure is critical due to the risk of hypotension.
A client is considering the contraceptive injection. Which of the following side effects should the nurse discuss?
- A. Permanent weight loss.
- B. Irregular menstrual bleeding.
- C. Guaranteed regular periods.
- D. Decreased bone density with long-term use.
Correct Answer: B,D
Rationale: The contraceptive injection can cause irregular menstrual bleeding and decreased bone density with long-term use, which are important side effects to discuss. It does not cause permanent weight loss or guarantee regular periods.
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says:
- A. I must use barrier isolation.
- B. I must wear a gown and gloves.
- C. I must use individual client care equipment.
- D. I must practice frequent hand washing.
Correct Answer: D
Rationale: Frequent hand washing is the most effective infection control measure for a respiratory tract infection.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
A client asks about the side effects of the contraceptive implant. Which of the following would the nurse include?
- A. Regular menstrual cycles are guaranteed.
- B. Irregular bleeding is a common side effect.
- C. It causes significant weight loss.
- D. It increases the risk of ovarian cysts.
Correct Answer: B
Rationale: Irregular bleeding is a common side effect of the contraceptive implant, especially in the first year. It does not guarantee regular cycles, cause significant weight loss, or significantly increase ovarian cyst risk.