Nokea
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 minutes.
- B. Contraction duration of 100 seconds.
- C. Fetal heart rate of 118/min.
- D. Fetal heart rate with moderate variability.
Correct Answer: B
Rationale: Contraction duration of 100 seconds exceeds the normal range (usually less than 90 seconds), risking uterine hyperstimulation and fetal compromise, necessitating oxytocin discontinuation.
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A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin.
- B. Azithromycin.
- C. Ceftriaxone.
- D. Acyclovir.
Correct Answer: A
Rationale: Ampicillin is a first-line antibiotic effective against group B streptococcus B-hemolytic bacteria, preventing neonatal infection during labor. It targets the bacterial cell wall synthesis and is safe in pregnancy.
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase your potassium intake.
- B. Increase your fluid intake to 3 liters per day.
- C. Refrain from consuming alcohol.
- D. Limit your daily intake of fiber.
Correct Answer: C
Rationale: Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
Drag words from the choices below to fill in each blank in the following sentence: The nurse should [option] as a potential complication.
- A. The nurse should plan to discuss with the client the risk for hypothyroidism.
- B. The nurse should include fallopian tube rupture as a potential complication.
- C. The nurse should explain hypovolemic shock as a life-threatening risk.
- D. The nurse should elaborate on the development of an invasive mole.
Correct Answer: B
Rationale: Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A yearly Pap test is recommended until 70 years of age.
- B. Pap tests are discontinued following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections can be detected by a Pap test.
Correct Answer: C
Rationale: Avoiding intercourse for 24 hours minimizes contamination of cervical cells with external materials, ensuring accurate Pap test results. It is an important preparatory guideline.