Nokea
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because obtaining informed consent ensures that the client understands the risks, benefits, and alternatives of the procedure. It also respects the client's autonomy and right to make decisions about their care.
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could potentially harm the client by causing urinary retention.
Summary: The correct action is to ensure informed consent is obtained, as it is a fundamental ethical and legal requirement in healthcare.
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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: D
Rationale: Reporting the client's HIV status to the local health department is required by law to ensure proper public health monitoring and intervention.
Which of the following is a potential ethical issue related to fetal surgery?
- A. Informed consent
- B. Allocation of resources
- C. End-of-life decision making
- D. All of the above
Correct Answer: A
Rationale: Informed consent is a key ethical issue in fetal surgery, ensuring parents understand the risks and benefits.
What is the recommended amount of weight gain during pregnancy for a woman with a normal BMI?
- A. 10-15 pounds
- B. 20-30 pounds
- C. 30-40 pounds
- D. 40-50 pounds
Correct Answer: B
Rationale: The correct answer is B (20-30 pounds). This range is recommended for pregnant women with a normal BMI to support the health of both the mother and the baby. Gaining too little weight can lead to complications like low birth weight, while gaining too much weight increases the risk of gestational diabetes and high blood pressure. The other choices are incorrect because they either fall below or exceed the recommended weight gain range, which can pose risks to the pregnancy. It is crucial for the mother to maintain a healthy weight gain to ensure a safe and successful pregnancy.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The absence of tears is a sign of severe dehydration, indicating the need for IV fluid therapy to restore hydration.