Nokea
A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?
- A. Asking the client to raise their eyebrows and looking for symmetry
- B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
- C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
- D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear
Correct Answer: D
Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).
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A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?
- A. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline
- B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds
- C. Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement
- D. Absence of accelerations after fetal movement
Correct Answer: D
Rationale: The correct answer is 'Absence of accelerations after fetal movement.' In a nonreactive (nonreassuring) stress test, the monitor recording would not show accelerations after fetal movement within a 40-minute period. This absence of accelerations indicates a nonreactive result. Choices A, B, and C describe different patterns of fetal heart rate accelerations that are not indicative of a nonreactive result in a nonstress test, making them incorrect. Choice A describes the characteristics of a reactive (reassuring) result, where there should be at least two fetal heart accelerations within a 20-minute period, peaking at least 15 beats/min above the baseline, and lasting 15 seconds from baseline to baseline. Choice B incorrectly states 'Accelerations without fetal movement,' which is contradictory. Choice C describes an acceleration response to fetal movement, which does not signify a nonreactive result.
A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?
- A. Notifying the healthcare provider
- B. Stopping the oxytocin infusion
- C. Checking the woman's blood pressure and pulse
- D. Increasing the intravenous (IV) rate of the nonadditive solution
Correct Answer: B
Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.
A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?
- A. Prone
- B. Standing
- C. Supine
- D. Hands and knees
Correct Answer: D
Rationale: During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?
- A. Initiate cardiopulmonary resuscitation
- B. Gently stimulate the infant by rubbing his back while administering oxygen
- C. Recheck the score in 5 minutes
- D. Provide no action except to support the infant's spontaneous efforts
Correct Answer: B
Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.
A client is taught about healthy dietary measures and the MyPlate food plan. How many of his grains should be whole grains according to the MyPlate food plan?
- A. One-quarter
- B. One-third
- C. One-half
- D. Two-thirds
Correct Answer: C
Rationale: The correct answer is 'One-half.' According to the MyPlate food plan, at least half of the grains consumed daily should be whole grains. This ensures a well-balanced and healthy diet. Choices A, B, and D are incorrect because they do not align with the dietary recommendation provided by the MyPlate food plan. One-quarter, one-third, and two-thirds do not represent the appropriate proportion of whole grains as advised by the plan, which emphasizes the importance of including a significant portion of whole grains in one's diet.