Nokea
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
- A. Variable decelerations are due to umbilical cord compression.
- B. Variable decelerations are caused by uteroplacental insufficiency.
- C. Variable decelerations are a result of the administration of IV narcotic analgesics.
- D. Variable decelerations are related to fetal head compression.
Correct Answer: A
Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.
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The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 2?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: B
Rationale: An MEC score of 2 indicates that there is an unacceptable health risk if the contraceptive method is used. This means that the potential health risks associated with using this particular contraceptive method outweigh the benefits. Therefore, the nurse should advise against using this method for contraception due to the elevated health risks involved. It is essential for healthcare providers to meticulously assess the medical eligibility of a patient before recommending any contraceptive method to ensure the safety and well-being of the individual.
The nurse is educating a client about Rh incompatibility. What statement indicates understanding?
- A. Rh incompatibility only occurs in first pregnancies.
- B. I will need Rho(D) immune globulin if my baby is Rh positive.
- C. Rh incompatibility is treated with antibiotics.
- D. Rh incompatibility does not affect the baby.
Correct Answer: B
Rationale: Rho(D) immune globulin prevents the mother's immune system from attacking Rh-positive fetal red blood cells.
The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
On admission to the nursery, a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time would be to minimize:
- A. Shivering
- B. Hyperglycemia
- C. Oxygen consumption
- D. Metabolism of fat stores
Correct Answer: C
Rationale: Cold stress in a newborn can lead to an increase in oxygen consumption as the body works harder to maintain a normal body temperature. By minimizing oxygen consumption, the nursing intervention aims to prevent excessive oxygen demand and help the newborn cope with the cold stress more effectively. This can be achieved through methods such as swaddling, warming equipment, and ensuring the baby's environment is appropriately heated to maintain a stable body temperature. Minimizing oxygen consumption can help conserve energy and promote overall well-being in the newborn.
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client who has a urinary output of 300 ml in 8 hr.
- B. A client who reports abdominal cramping during breastfeeding
- C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes
- D. A client who reports lochia rubra requiring changing perineal pads every 3 hr.
Correct Answer: C
Rationale: The nurse should notify the provider for the client who is receiving magnesium sulfate and has absent deep tendon reflexes. Absent deep tendon reflexes are a sign of magnesium toxicity, which can lead to serious complications such as respiratory depression, cardiac arrest, and death. Prompt intervention by the provider is necessary to adjust the magnesium sulfate dosage and prevent further harm to the client.