Nokea
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: Late decelerations in the fetal heart rate are a sign of fetal distress and contraindicate the use of oxytocin, as it can exacerbate the distress.
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A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C - Hypotension
Rationale: Opioid analgesics can cause hypotension as a side effect by vasodilation and reduced cardiac output. The epidural route can further exacerbate this effect due to the potential spread of the medication to sympathetic nerves, resulting in vasodilation and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications such as decreased tissue perfusion and potential cardiovascular collapse.
Incorrect Choices:
A: Hyperglycemia - Opioids do not typically cause hyperglycemia.
B: Bilateral crackles - Crackles are not a common adverse effect of opioids.
D: Polyuria - Opioids do not usually cause polyuria.
The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale:
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels to rule out hypoglycemia. Newborns are at risk for hypoglycemia due to limited glycogen stores and high metabolic demands. Untreated hypoglycemia can lead to serious complications like seizures and brain damage. Total bilirubin (choice B) is important for assessing jaundice but is not the priority in this case. Hemoglobin (choice C) and blood calcium (choice D) are not typically the first considerations for jitteriness in a newborn.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn’s skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is essential during phototherapy to maximize the skin's exposure to the light. The light helps breakdown bilirubin in the skin, reducing jaundice. Choice A is incorrect as water will not treat hyperbilirubinemia. Choice B is incorrect as lotions can interfere with the effectiveness of phototherapy. Choice D is incorrect as a rash is a common side effect of phototherapy and should not lead to discontinuation unless severe.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: Decreased temperature, lethargy, poor feeding, and respiratory distress are consistent with sepsis. Yellow sclera and oral mucosa are consistent with hyperbilirubinemia.