Nokea
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
- A. Perform fundal massage
- B. Document the exact time of events
- C. Flex the client's legs back against the abdomen
- D. Request immediate assistance from other nurses
- E. Apply downward pressure above the client's symphysis pubis
Correct Answer: B,C,D,E
Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.
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The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.
A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?
- A. Send her home without seeing the doctor if she is not available when called
- B. Give her advance warning that she will be seeing the physician and tell her that if she needs to wash her hands, she should do so
- C. Interrupt her washing ritual and insist that she see the physician when it is her turn
- D. Give her a choice of seeing the physician or washing her hands
Correct Answer: B
Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.
The perinatal nurse is reviewing telephone messages from clients. The nurse should first telephone the client who is at
- A. 18 weeks gestation, is taking ceftriaxone, and reports mild diarrhea
- B. 22 weeks gestation and is taking acetaminophen twice daily
- C. 28 weeks gestation, is taking metronidazole, and reports dark colored urine
- D. 32 weeks gestation and is taking ibuprofen daily
Correct Answer: D
Rationale: Ibuprofen at 32 weeks gestation is concerning due to risks of premature ductus arteriosus closure and oligohydramnios, requiring immediate follow-up. Mild diarrhea and dark urine with metronidazole are less urgent, and acetaminophen is safe.
The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.
- A. Consult the health care provider (HCP) if you experience leg pain or swelling
- B. Discontinue contraceptives if you experience spotting between menses
- C. Do not smoke while taking combined contraceptives
- D. Immediately report any breast tenderness to the HCP
- E. Seek immediate medical treatment if you experience vision loss
Correct Answer: A,C,E
Rationale: For combined oral contraceptives: report leg pain/swelling for possible DVT; avoid smoking due to increased cardiovascular risk; and seek treatment for vision loss indicating possible stroke. Spotting is common and breast tenderness is not urgent.
A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action?
- A. Auscultate the child's lung fields
- B. Have the child take slow, deep breaths
- C. Increase the oxygen flow rate to 3 L/min
- D. Verify the position and integrity of the finger probe
Correct Answer: D
Rationale: An inaccurate pulse oximeter reading may result from a poorly positioned probe. Verifying the probe's position is the initial action. Auscultation , deep breaths , or increasing oxygen are secondary without confirming the reading.