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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: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, potentially leading to fetal distress. Oxytocin can further stress the fetus by increasing uterine contractions, exacerbating the late decelerations. Late decelerations are a sign of decreased oxygen supply to the fetus, making it unsafe to augment labor with oxytocin. Therefore, this finding should be reported to the provider to ensure the safety of both the client and the fetus.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being, not a contraindication for oxytocin infusion.
C: Cessation of uterine dilation may indicate a stalled labor progress but is not a contraindication for initiating oxytocin.
D: Prolonged active phase of labor may warrant augmentation with oxytocin rather than being a contraindication.
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A nurse is reviewing the provider's prescription in the adolescent's
medical chart.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and ---------------------------------
- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: The correct answer is A,B. First, providing education on medications is crucial to ensure the adolescent understands the prescribed treatment. This empowers them to adhere to the regimen, promoting better health outcomes. Second, administering ceftriaxone aligns with the provider's prescription and is a direct action the nurse must take to carry out the treatment plan. Choices C, D, E, F, and G are incorrect because administering metronidazole and educating on condom use (C) is not the immediate priority. Administering metronidazole is not mentioned in the provider's prescriptions, so it is not the first step. Choices D, E, F, and G are irrelevant and not related to the provider's prescriptions or the adolescent's care.
The nurse is reviewing laboratory results in the adolescent's medical
record.
Exhibit 1
Vital Signs
1300:
Blood pressure 118/72 mm Hg
Heart rate 100/min
Respiratory rate 20/min
Temperature 38.3° C (101° F)
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: Correct Answer: A: Pelvic inflammatory disease
Rationale: Pelvic inflammatory disease (PID) is a common condition in adolescents due to sexually transmitted infections. The nurse reviewing the medical record indicates a focus on the reproductive system. Ectopic pregnancy and Beta hCG levels are related but not the most likely in this case. C-reactive protein and urinalysis are general tests not specific to PID.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: The correct answer is C. Continuing to take insulin even if experiencing nausea and vomiting is crucial in managing blood glucose levels in type 1 diabetes during pregnancy. Nausea and vomiting can lead to decreased food intake, potentially causing hypoglycemia if insulin is not adjusted. Increasing insulin doses in the first trimester (choice A) is not recommended without healthcare provider guidance. Engaging in moderate exercise with high blood glucose (choice B) could worsen hyperglycemia. Ensuring a bedtime snack high in refined sugar (choice D) may lead to unstable blood glucose levels.
A nurse is caring for a postpartum client in an outpatient setting
Exhibit1:
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.
Newborn 4,508 g (9 lb 15 oz), APGARs: 8 at 1 min, 9 at 5 min
group B streptococcus 8-hemolytic: positive (negative)
Received 2 doses of Intravenous penicillin G while in labor”
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
- A. Endometritis.
- B. Mastitis.
- C. Postpartum hemorrhage.
- D. Group B streptococcus positive status.
- E. Spontaneous vaginal delivery.
- F. Median episiotomy.
Correct Answer: A
Rationale: The correct answer is A: Endometritis. The client is at highest risk for developing endometritis evidenced by the client's median episiotomy. Endometritis is an infection of the lining of the uterus and is commonly associated with invasive procedures like episiotomy. The incision from a median episiotomy provides a pathway for bacteria to enter the uterus, increasing the risk of infection. The other choices are incorrect because mastitis is related to breastfeeding, postpartum hemorrhage is excessive bleeding after childbirth, group B streptococcus positive status is a risk for neonatal infection, and spontaneous vaginal delivery is a mode of delivery not directly related to endometritis.
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (A) to monitor for preterm labor, fetal heart rate (B) to assess fetal well-being, and vaginal examination (D) to evaluate cervical changes. Gestational age (C) is typically known and doesn't require immediate reporting. Maternal blood pressure (E) is important but not a priority in this context.