Nokea
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. This action is appropriate because late decelerations in fetal heart rate (FHR) can indicate uteroplacental insufficiency, leading to fetal hypoxia. Administering oxygen helps increase the oxygen supply to the fetus, potentially improving fetal oxygenation and reducing the risk of hypoxia-related complications.
Choice A is incorrect because bearing down and pushing with contractions can further compromise fetal oxygenation in the presence of late decelerations. Choice C is incorrect as a supine position can worsen uteroplacental perfusion. Choice D, initiating an amnioinfusion, is not indicated for addressing late decelerations in FHR.
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A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B. Maternal cytomegalovirus can be transmitted to the newborn through saliva and urine. This is important for healthcare providers to understand as it influences infection control practices in the care of both the mother and the newborn. The other choices are incorrect because: A) Acyclovir is used to treat herpes simplex virus, not cytomegalovirus. C) Lesions are not typically visible on the mother's genitalia with cytomegalovirus. D) Airborne precautions are not required for cytomegalovirus as it is primarily transmitted through bodily fluids.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention. Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is appropriate as the client is experiencing postpartum hemorrhage, which can lead to hypovolemic shock. Administering IV fluids helps increase circulating volume and stabilize the client's condition. The other choices are incorrect because: A) Replacing the surgical dressing does not address the underlying issue of hemorrhage. B) Evaluating urinary output is important but not the priority when the client is actively bleeding. C) Applying an ice pack to the incision site is not indicated and may not address the hemorrhage. Overall, choice D is the most crucial intervention to address the immediate concern of postpartum hemorrhage.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). A high fasting blood glucose level during pregnancy may indicate gestational diabetes, which can lead to complications for both the mother and the fetus. The nurse should report this finding to the provider for further evaluation and management to prevent adverse outcomes.
Choice A: Hematocrit of 37% falls within the normal range for a pregnant woman and does not require immediate reporting.
Choice B: Creatinine level of 0.9 mg/dL is within the normal range and does not indicate any immediate concerns.
Choice C: WBC count of 11,000/mm3 is slightly elevated but can be a normal response to pregnancy and does not typically require immediate action.
In summary, the correct answer is D because it indicates a potentially serious condition that requires further investigation, while choices A, B, and C are within normal limits for pregnancy and do not raise immediate concerns.