Nokea
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.
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A patient has delivered twins. The first twin was stillborn, and the second is in the intensive care nursery, recovering quickly from respiratory distress. The patient is crying softly and says, "wish my baby could have lived." What is the most therapeutic response?
- A. "How soon do you plan to have another baby?"
- B. "Don't be sad. At least you have one healthy baby."
- C. "have a friend who lost a twin and she's doing just fine now."
- D. "am so sorry about your loss. Would you like to talk about it?"
Correct Answer: D
Rationale: The correct answer is D because it shows empathy, acknowledges the patient's loss, and invites further discussion if the patient wishes to talk. It validates the patient's feelings and offers support. Choice A is inappropriate as it disregards the patient's current emotional state. Choice B diminishes the patient's grief and may come off as insensitive. Choice C redirects the focus to someone else's experience, which may not be helpful in addressing the patient's emotions.
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.
Which of the following findings would indicate
- A. Reversal of a tubal ligation is easily done, with a an infant who may be considered preterm?
- B. Labia minora are larger than labia majora
- C. After this procedure, I must abstain from inter-
- D. Plantar creases cover two-thirds of foot
Correct Answer: D
Rationale: The correct answer is D because plantar creases covering two-thirds of the foot is a typical finding in Down syndrome. This is known as the Sandal gap sign, which is a characteristic feature of Down syndrome. The other choices are incorrect because: A is not related to any specific medical condition, B describes a normal anatomical variation, and C is incomplete and does not provide enough information to determine its relevance.
A client at 10 weeks' gestation reports frequent nausea. What dietary advice should the nurse provide?
- A. Consume small, frequent meals throughout the day.
- B. Avoid eating before going to bed.
- C. Drink large amounts of fluids with meals.
- D. Eat only three large meals daily.
Correct Answer: A
Rationale: The correct answer is A. Consuming small, frequent meals helps manage nausea by preventing an empty stomach, which can worsen symptoms. Eating smaller meals throughout the day can help stabilize blood sugar levels and provide a constant source of nutrients. This approach is recommended for managing nausea during early pregnancy.
Choice B is incorrect because avoiding eating before bed does not address the underlying issue of nausea during the day.
Choice C is incorrect because drinking large amounts of fluids with meals may worsen nausea by causing bloating and discomfort.
Choice D is incorrect because eating only three large meals daily can lead to periods of fasting in between meals, which may exacerbate nausea.
A woman asks about the side effects of the contraceptive implant. Which of the following should the nurse include in the discussion?
- A. The implant will cause heavy menstrual bleeding.
- B. The implant may cause irregular bleeding patterns, including light spotting.
- C. The implant can cause weight gain.
- D. The implant may cause hair loss.
Correct Answer: B
Rationale: The correct answer is B because irregular bleeding patterns, including light spotting, are a common side effect of the contraceptive implant due to hormonal changes. This is important for the woman to be aware of to manage her expectations. Choice A is incorrect as the implant typically leads to lighter periods or no periods at all. Choice C is incorrect as weight gain is not a common side effect of the implant. Choice D is also incorrect as hair loss is not typically associated with the contraceptive implant.