Nokea
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.
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The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
What can self-awareness with postural adjustments lead to?
- A. tension formation
- B. tension release
- C. suboptimal posture
- D. back pain
Correct Answer: B
Rationale: Self-awareness with postural adjustments can lead to tension release because it allows individuals to identify and correct any muscular imbalances or poor postural habits. By being aware of their body positioning and making necessary adjustments, individuals can reduce muscle tension and promote proper alignment, leading to relaxation and alleviation of tension. This proactive approach helps prevent the buildup of tension in muscles, ultimately promoting overall well-being.
Incorrect Choices:
A: Tension formation - Self-awareness with postural adjustments helps prevent tension formation by addressing imbalances.
C: Suboptimal posture - Self-awareness promotes optimal posture by making adjustments.
D: Back pain - Proper postural adjustments can alleviate back pain, not cause it.
Immediately after the forceps assists in the birth of an infant, what should the nurse do with the baby?
- A. Assess infant for signs of trauma
- B. Administer a vitamin K injection
- C. Provide immediate breastfeeding
- D. Monitor for signs of hypoglycemia
Correct Answer: A
Rationale: Rationale: Immediately after forceps-assisted birth, assessing the infant for signs of trauma is crucial for detecting any injuries or complications. This ensures prompt intervention if needed. Administering a vitamin K injection, providing immediate breastfeeding, and monitoring for hypoglycemia are important but secondary tasks that can be done after ensuring the infant's safety.
The nurse is reviewing a prenatal chart and notes a client with placenta previa. What is the priority nursing consideration?
- A. Encourage vaginal delivery.
- B. Avoid vaginal examinations.
- C. Encourage bed rest at home.
- D. Prepare for immediate induction of labor.
Correct Answer: B
Rationale: The correct answer is B: Avoid vaginal examinations. Placenta previa is a condition where the placenta partially or completely covers the cervix, increasing the risk of bleeding. Vaginal examinations can trigger bleeding by disrupting the placenta. The priority is to minimize the risk of bleeding and prevent complications. Encouraging vaginal delivery (A) is contraindicated due to the risk of hemorrhage. Bed rest at home (C) may be recommended but is not the priority. Immediate induction of labor (D) can be dangerous and is not indicated unless there is an emergency situation.
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.