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. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen to the mother increases oxygen delivery to the fetus, improving oxygenation and potentially reversing the late decelerations. Other choices are incorrect: A could increase intra-abdominal pressure, worsening late decelerations. C can decrease placental perfusion. D is not indicated for late decelerations.
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Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G.
A: Coombs test result is crucial for diagnosing hemolytic anemia.
B: Mucous membrane assessment reflects hydration and oxygenation status.
C: Intake and output are vital for monitoring fluid balance.
G: Sclera color can indicate jaundice or liver dysfunction.
Other choices like D, E, and F are important assessments but not as critical for immediate provider notification. The respiratory rate (D) and heart rate (F) are essential vital signs but can be monitored routinely. Head assessment findings (E) can be important but may not require immediate provider notification unless there is a significant change.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is delivered with a nuchal cord (around the neck), it can cause pressure on the baby's face during delivery, leading to tiny broken blood vessels called petechiae. This is a common finding in newborns with nuchal cords due to the pressure exerted on the face. Telangiectatic nevi (A), periauricular papillomas (C), and erythema toxicum (D) are not typically associated with nuchal cords. Petechiae is the most likely finding in this scenario.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: Correct Answer: A. "I should empty my bladder before the procedure."
Rationale: Emptying the bladder before amniocentesis helps avoid accidental puncture during the procedure. A full bladder can be in the needle's path, increasing the risk of injury. This statement demonstrates the client's understanding of the importance of bladder emptying.
Incorrect Choices:
B: "I will be lying on my side during the procedure." - Incorrect. The client will typically be lying flat on their back during amniocentesis.
C: "I will be asleep during the procedure." - Incorrect. Amniocentesis is usually done with local anesthesia, so the client will be awake.
D: "I should start fasting 24 hours before the procedure." - Incorrect. Fasting is not required for amniocentesis. It is a simple procedure that does not involve general anesthesia or fasting.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Hematuria and Proteinuria 2+ are relevant findings that may indicate a potential worsening condition.
- Leukorrhea is unrelated to the diagnosis and should not be considered for interpretation.
- Positive clonus is a sign of potential improvement as it suggests a neurological response.
- BUN 40 mg/dL is a critical value that indicates potential renal impairment.
- Platelet count 110,000/mm3 is a concerning finding that suggests a potential worsening condition.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce swelling, promote healing, and provide comfort for the client with a fourth-degree laceration. Warm compress can improve circulation and help with pain relief.
Choice B: Providing a cool sitz bath may not be ideal for promoting healing in this case as warmth is more beneficial.
Choice C: Administering methylergonovine is not appropriate for a perineal laceration and can cause unwanted side effects.
Choice D: Applying povidone-iodine after voiding can be irritating to the already sensitive area and may delay healing.