Nokea
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing preterm labor at 26 weeks of gestation.
- B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.
- C. A client who has a post-term pregnancy at 42 weeks of gestation.
- D. A client who is experiencing fetal death at 32 weeks of gestation.
Correct Answer: A
Rationale: The correct answer is A: A client who is experiencing preterm labor at 26 weeks of gestation. Tocolytic therapy is used to inhibit uterine contractions and delay preterm labor. Administering tocolytic therapy to a client experiencing preterm labor at 26 weeks helps prevent premature birth and its associated complications. Choices B, C, and D are incorrect because Braxton-Hicks contractions at 36 weeks, post-term pregnancy at 42 weeks, and fetal death at 32 weeks do not warrant tocolytic therapy as they are not indicative of preterm labor.
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A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
- A. Dorsogluteal
- B. Vastus lateralis
- C. Deltoid
- D. Ventrogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice D) can be used in older infants but is not the preferred site for newborns.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use
- B. Blunt force trauma
- C. Hypertension
- D. Cigarette smoking
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption because it can lead to reduced blood flow to the placenta, increasing the risk of separation. High blood pressure can cause damage to the blood vessels in the placenta, making it more susceptible to detachment. Cocaine use (A) and cigarette smoking (D) can also increase the risk of abruption, but they are not as common as hypertension. Blunt force trauma (B) can directly cause placental abruption but is not as prevalent as hypertension in this context.
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?
- A. Witness the signature for informed consent for surgery.
- B. Initiate IV access.
- C. Insert an indwelling urinary catheter.
- D. Prepare the abdominal and perineal areas.
Correct Answer: B
Rationale: The correct answer is B: Initiate IV access. The priority nursing action in this scenario is to ensure IV access to administer necessary medications or fluids in case of an emergency. The client's vital signs indicate hypotension and tachycardia, which could be signs of hypovolemic shock due to significant bleeding. Initiating IV access promptly can help stabilize the client's condition and prevent further complications.
Choice A is incorrect because obtaining informed consent for surgery is not the immediate priority in this situation. Choice C is incorrect as inserting a urinary catheter is not urgent compared to addressing the potential hypovolemia. Choice D is incorrect as preparing the abdominal and perineal areas is not as urgent as addressing the client's hemodynamic instability.
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
- A. Administer oxygen by non-rebreather mask at 5 L/min
- B. Obtain laboratory study of prothrombin and partial thromboplastin time
- C. Methylergonovine 0.2 mg IM now
- D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The correct answer is C: Methylergonovine 0.2 mg IM now. This prescription requires clarification because methylergonovine is a uterotonic medication that can cause severe vasoconstriction, leading to increased blood pressure. Given the client's elevated blood pressure of 146/94 mm Hg, administering methylergonovine could potentially worsen hypertension and lead to adverse effects such as stroke or myocardial infarction. It is crucial to address the high blood pressure before considering the administration of methylergonovine. The other options are not immediately concerning: A) Administering oxygen is appropriate for a client with elevated blood pressure; B) Obtaining laboratory studies is a routine part of postpartum care to assess for coagulation abnormalities; D) Inserting an indwelling urinary catheter is commonly done postpartum to monitor urinary output.