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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: The correct answer is A: Determine respiratory function. This is the priority because an unresponsive client may be experiencing respiratory distress, which can quickly lead to hypoxia and cardiac arrest. Assessing respiratory function allows the nurse to intervene promptly if needed. Increasing IV fluid rate (B) is important but not the first priority. Accessing emergency medications (C) may be necessary, but addressing respiratory status comes first. Collecting a blood sample for coagulopathy studies (D) is important for assessing bleeding disorders but is not the immediate priority in this situation.
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A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 8 tablets
- B. 6 tablets
- C. 4 tablets
- D. 2 tablets
Correct Answer: C
Rationale: The correct answer is C: 4 tablets. Azithromycin 1g is equivalent to 1000mg. Since each tablet is 250mg, the nurse should administer 1000mg/250mg = 4 tablets. This dosage is appropriate for treating chlamydia infection. Choice A is incorrect because 8 tablets would be equivalent to 2000mg, which is double the prescribed dosage. Choice B is incorrect as 6 tablets would be 1500mg, which is higher than the prescribed dosage. Choice D is incorrect as 2 tablets would only be 500mg, which is lower than the prescribed dosage.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Before applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the fetal position, presentation, and lie. This helps in correctly placing the transducer over the fetal heart for accurate monitoring. Progression of dilatation and effacement (A) is not necessary prior to applying the external transducer. Completing a sterile speculum exam (C) and preparing a Nitrazine paper test (D) are unrelated to fetal monitoring and are not indicated in this situation.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying can help soothe the baby by providing comfort and closeness. This position mimics the feeling of being held in the womb and the swaying motion can be calming. Placing the newborn in the crib in a prone position (B) is not recommended due to the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may lead to overfeeding and potential nipple confusion. Preparing a bottle of formula mixed with rice cereal (D) is not recommended for newborns as their digestive systems are not ready for solids.
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 correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.