Nokea
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: C
Rationale: The correct answer is C: 6 contractions in 10 minutes. This indicates hyperstimulation of the uterus, putting the fetus at risk. Discontinuing oxytocin is necessary to prevent uterine tachysystole. Contractions lasting 60 seconds (choice A) are normal. Non-repetitive early decelerations (choice B) are benign. Moderate variability of the fetal heart rate (choice D) is a reassuring sign of fetal well-being.
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A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
- A. Apply a thin layer lotion to the newborn skin every 8 hours
- B. Trust in you born in a thin layer clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage. Choice A is incorrect as lotion can intensify the effects of phototherapy. Choice B is incorrect as the newborn should be undressed to maximize skin exposure. Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.
A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider?
- A. Fasting blood glucose 75 mg / DL
- B. Blood pressure 88/58 mmhg
- C. Urinary output 40 ml /hr
- D. FHR 120/min
Correct Answer: B
Rationale: The correct answer is B: Blood pressure 88/58 mmHg. Terbutaline is a tocolytic medication used to stop preterm contractions. A low blood pressure reading of 88/58 mmHg may indicate hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased placental perfusion, putting the fetus at risk. The nurse should withhold the medication and report this finding to the provider for further assessment and intervention.
A: Fasting blood glucose of 75 mg/dL is within normal range and does not require withholding the medication.
C: Urinary output of 40 ml/hr is adequate and does not indicate a need to withhold the medication.
D: Fetal heart rate of 120/min is within the normal range for a fetus and does not require withholding the medication.
A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele9s rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation.
- A. 05/11
- B. 5/4
- C. 5/12
- D. 04/27
Correct Answer: A
Rationale: The correct answer is A: 05/11. Using Naegele's rule, add 7 days to the first day of the last menstrual period (March 20), subtract 3 months, and add 1 year. March 20 + 7 days = March 27. Subtracting 3 months gives us December 27. Adding 1 year brings us to December 27 of the following year. However, since we are looking for the estimated date of delivery, we add 7 days to adjust for the 7 days we added at the beginning, which gives us May 4. Therefore, the estimated date of delivery would be May 11. Choice B (5/4) is incorrect because it does not account for the 7-day adjustment. Choice C (5/12) is incorrect as it adds 7 days twice. Choice D (04/27) is incorrect as it doesn't correctly follow Naegele's rule.
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Firm rigid abdomen
- B. Painless, vaginal bleeding
- C. Uterine hypertonicity
- D. Persistent headache
Correct Answer: B
Rationale: The correct answer is B: Painless, vaginal bleeding. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless, bright red bleeding in the third trimester. This occurs because the placenta is located close to or over the cervical opening, causing it to bleed with minimal trauma. It is important for the nurse to recognize this sign as it can lead to maternal and fetal complications if not managed promptly. Choices A, C, and D are incorrect because they do not align with the typical presentation of placenta previa. A firm rigid abdomen is more indicative of a condition like placental abruption. Uterine hypertonicity is not a common finding in placenta previa. Persistent headache is not a characteristic symptom of placenta previa and may be indicative of other conditions like preeclampsia.
A nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis - i think this is referring to acrocyanosis which is normal
- B. Single Palmar creases - down syndrome - p.27
- C. Subconjunctival hemorrhage - expected
- D. Rust stain urine - expected
Correct Answer: B
Rationale: The correct answer is B: Single Palmar creases - down syndrome. This finding should be reported to the provider because it is a physical characteristic associated with Down syndrome. The presence of a single palmar crease can indicate a chromosomal abnormality and requires further evaluation.
A: Transient circumoral cyanosis is a common finding in newborns and is typically related to acrocyanosis, which is considered normal in the immediate postnatal period.
C: Subconjunctival hemorrhage is a common occurrence during the birth process and is often benign, resolving on its own without intervention.
D: Rust stain urine may be a result of uric acid crystals and is considered expected in newborns due to the metabolism of fetal hemoglobin. It does not typically require immediate reporting to the provider.
In summary, the other choices are considered normal or expected in newborns, while the presence of a single palmar crease requires further assessment due to its association with Down syndrome.