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A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.
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A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
- A. Varicella
- B. Human papillomavirus
- C. Diphtheria - acellular pertussis
- D. Inactivated influenza
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (A) and Human papillomavirus (B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
A nurse is caring for a client who has a complete uterine rupture. Which of the following findings should the nurse expect?
- A. Early fetal heart rate decelerations
- B. Hypotension
- C. Painless, dark red vaginal bleeding
- D. bounding peripheral pulses
Correct Answer: B
Rationale: The correct answer is B: Hypotension. A complete uterine rupture is a serious complication where the uterine wall tears completely, leading to massive internal bleeding. This can result in hypotension due to blood loss. Early fetal heart rate decelerations (choice A) are not indicative of uterine rupture. Painless, dark red vaginal bleeding (choice C) is more commonly associated with placental abruption. Bounding peripheral pulses (choice D) are not a typical finding in uterine rupture.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring is a sign of respiratory distress, which is a priority because it indicates potential respiratory compromise. The nurse should assess this newborn first to ensure adequate oxygenation. Subconjunctival hemorrhage (choice B) and overlapping suture lines (choice C) are common findings in newborns and typically do not require immediate attention. Rust-stained urine (choice D) is not a concerning finding in a newborn and can be addressed later.