Nokea
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Fundus firm to palpation
- B. Increase in blood pressure
- C. Increase in lochia
- D. Report of absent breast pain .
Correct Answer: A
Rationale: Step 1: Methylergonovine is a uterotonic drug used to prevent or treat postpartum hemorrhage by causing uterine contractions.
Step 2: Fundus firmness indicates effective contraction of the uterus, helping to control bleeding.
Step 3: A firm fundus also suggests proper involution of the uterus, a crucial process in postpartum recovery.
Step 4: Increase in blood pressure (B) is not a desired effect of methylergonovine and could indicate adverse reactions.
Step 5: Increase in lochia (C) could suggest excessive bleeding or incomplete uterine contraction.
Step 6: Absence of breast pain (D) is not directly related to the effectiveness of methylergonovine in controlling postpartum bleeding.
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The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.
A nurse is caring for a client who is receiving Iv magnesium sulfate which of the following medication should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine (Adalat)
- B. Pyridoxine (vitamin B)
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. In cases of magnesium sulfate toxicity, calcium gluconate is administered as an antidote due to its ability to counteract the effects of magnesium. Magnesium and calcium ions have an antagonistic relationship in the body, so administering calcium gluconate can help reverse the toxic effects of magnesium. Nifedipine (A), Pyridoxine (B), and Ferrous sulfate (C) do not have a direct antidote effect on magnesium toxicity and are not indicated for this purpose.
The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
A client at 39 weeks' gestation reports sudden gush of fluid. What is the nurse's priority action?
- A. Perform a sterile vaginal exam.
- B. Assess fetal heart rate.
- C. Check maternal vital signs.
- D. Administer IV fluids.
Correct Answer: B
Rationale: The correct answer is B: Assess fetal heart rate. The priority action in this situation is to assess the well-being of the fetus since the client reported a sudden gush of fluid, which could indicate rupture of membranes. Assessing the fetal heart rate helps determine if the fetus is experiencing distress. Performing a sterile vaginal exam (A) can introduce infection and is not the priority. Checking maternal vital signs (C) can be done after assessing the fetal well-being. Administering IV fluids (D) is not the priority until the fetal status is determined.