Nokea
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic sac. Monitoring the client's temperature is crucial as fever can indicate infection, which can be life-threatening for both the client and the fetus. It is essential to detect early signs of infection to initiate prompt treatment. Assessing O2 saturation, blood pressure, and urinary output are important but not the priority in this situation. O2 saturation may be monitored if there are concerns about fetal distress, blood pressure for signs of preeclampsia, and urinary output for kidney function, but these are not immediate concerns post-amniotomy.
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Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Contractions every 5 min that last 30 seconds
- B. Montevideo units consistently 300 mm Hg
- C. Urine output of 20 mL/hr
- D. FHR pattern with absent variability
Correct Answer: A
Rationale: The correct answer is A because contractions every 5 minutes that last 30 seconds indicate increased frequency and duration, which may not be sufficient for effective labor progress. Increasing the rate of oxytocin can help strengthen contractions for more efficient labor. Choices B, C, and D do not indicate the need to increase the rate of infusion. Montevideo units measure the strength of contractions, urine output reflects renal perfusion, and absent variability in fetal heart rate suggests fetal distress, not the need for increased oxytocin.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring proper identification is crucial for providing safe and effective care. By verifying the newborn's identification, the nurse can confirm they are caring for the right baby, preventing any potential errors in treatment or medication administration. This step is essential in maintaining patient safety and preventing harm.
Confirming the Apgar score (choice A) can be important but is not the first priority in this scenario. Administering vitamin K (choice C) is a routine procedure but can be done after verifying identification. Determining obstetrical risk factors (choice D) is important for overall assessment but is not the immediate priority.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. A newborn who is 32 hr old and has not passed a meconium stool should be reported to the provider. Meconium should be passed within the first 24-48 hours of life, so the delay could indicate an obstruction or other issue. Choices A, C, and D are all within normal ranges for newborn assessments and do not require immediate reporting to the provider. E, F, and G are not provided as options.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.