Nokea
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
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Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Raise the head of the client's bed to a high-fowlers position.
- B. Elevate the clients effected leg on a pillow when in bed.
- C. Position the clients knees slightly higher than the hips when up in a chair
- D. Keep an abduction pillow between the client's legs.
Correct Answer: D
Rationale: The correct answer is D: Keep an abduction pillow between the client's legs. This helps maintain proper alignment and prevents excessive internal rotation of the hip, reducing the risk of dislocation. Elevating the affected leg on a pillow (B) may not provide adequate support. Raising the head of the bed to a high-fowlers position (A) and positioning the knees higher than the hips (C) do not directly address hip alignment.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.
- B. I will obtain the client's weight every other day.
- C. I will monitor the client's blood glucose level every eight hours.
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct answer is A because hanging a new bag of TPN and IV tubing every 24 hours helps to prevent bacterial growth and contamination, ensuring the client's safety. TPN solutions are prone to bacterial contamination if left hanging for too long, so changing the bag and tubing every 24 hours is crucial.
Summary of incorrect choices:
B: Obtaining the client's weight every other day is important for monitoring the effectiveness of TPN therapy, but it does not specifically address the procedure for administering TPN.
C: Monitoring the client's blood glucose level every eight hours is essential for managing TPN therapy, but it does not directly relate to the procedure of administering TPN.
D: Increasing the rate of TPN infusion without proper authorization or assessment can lead to serious complications such as hyperglycemia or fluid overload, making this choice incorrect.
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
The client is at risk for developing------- and----
- A. bronchopulmonary dysplasia
- B. transient tachypnea of the newborn
- C. tachycardia
- D. hypopycemia
Correct Answer: B,D
Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.