Nokea
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from the cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: Determining respiratory function is the first priority in an unresponsive client to ensure that the airway is patent and the client is breathing.
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A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the correct dosage, divide the total dose by the dose per tablet. In this case, 2 g = 2000 mg, and each tablet is 250 mg. Therefore, 2000 mg ÷ 250 mg = 8 tablets. This ensures the client receives the correct dosage for effective treatment. Choice B (4 tablets) would result in an underdose, C (2 tablets) would be half the required dose, and D (1 tablet) would be significantly lower than the needed dose, leading to ineffective treatment.
What is the recommended age for the first hepatitis B vaccine for a newborn?
- A. At birth
- B. Within 48 hours of birth
- C. Within 1 week of birth
- D. Within 1 month of birth
Correct Answer: B
Rationale: The correct answer is B: Within 48 hours of birth. This is recommended because newborns are most susceptible to hepatitis B infection during delivery. Administering the vaccine within 48 hours provides early protection. Choice A (At birth) is not specific enough and may delay vaccination. Choices C and D are too late and leave the newborn vulnerable for a longer period.
What is the function of the amniotic fluid during pregnancy?
- A. To protect the fetus from trauma
- B. To regulate fetal temperature
- C. To facilitate fetal movement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Amniotic fluid serves multiple functions during pregnancy. It protects the fetus from trauma by acting as a cushion. It helps regulate fetal temperature by maintaining a stable environment. It also facilitates fetal movement by allowing the fetus to move freely. Therefore, D is the correct choice as it encompasses all the essential functions of amniotic fluid. Choices A, B, and C are incorrect as they only represent individual functions of amniotic fluid, while the correct answer D covers all these functions comprehensively.
Which of the following is a potential complication of a breech delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Birth trauma
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Birth trauma. In a breech delivery, where the baby is positioned feet or buttocks first, there is an increased risk of birth trauma due to potential difficulties in delivering the baby's head, leading to possible injuries such as fractures or nerve damage. Fetal distress and maternal hemorrhage can also occur but are not exclusive complications of breech delivery. Choice D, "All of the above," is incorrect as not all potential complications of a breech delivery are listed.
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels to rule out hypoglycemia. Newborns are at risk for hypoglycemia due to limited glycogen stores and high metabolic demands. Untreated hypoglycemia can lead to serious complications like seizures and brain damage. Total bilirubin (choice B) is important for assessing jaundice but is not the priority in this case. Hemoglobin (choice C) and blood calcium (choice D) are not typically the first considerations for jitteriness in a newborn.