Nokea
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates poor uterine tone, which can lead to postpartum hemorrhage. Oxytocin is given to enhance uterine contractions and tone, helping prevent excessive bleeding. Excess vaginal bleeding is also an indication for oxytocin administration as it can help control bleeding by promoting uterine contractions. Choices B, D, and other options are incorrect as they do not directly relate to the need for oxytocin administration in this scenario. Cervical laceration and increased afterbirth cramping may require other interventions, but they do not specifically indicate the need for oxytocin administration to address postpartum bleeding.
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Which of the following hormones is responsible for inducing ovulation?
- A. Estrogen
- B. Progesterone
- C. Follicle-stimulating hormone (FSH)
- D. Luteinizing hormone (LH)
Correct Answer: D
Rationale: The correct answer is D: Luteinizing hormone (LH). LH surge triggers ovulation by stimulating the release of the mature egg from the ovarian follicle. Estrogen and progesterone play roles in the menstrual cycle but do not directly induce ovulation. FSH is involved in follicular development but not ovulation.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Sweiling of the face
Correct Answer: D
Rationale: Swelling of the face can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Other options like bleeding gums, faintness upon rising, and urinary frequency are common during pregnancy and not typically concerning unless severe.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A, to administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves or blood vessels. This site is typically used for vaccines in infants to ensure proper absorption and minimize discomfort. Option B is incorrect as massaging the site can lead to discomfort or tissue damage. Option C is incorrect as inserting the needle at a 45° angle is not necessary for intramuscular injections in newborns. Option D is incorrect as a smaller gauge needle is usually recommended for newborns to reduce pain and tissue trauma.
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves and blood vessels. It is located on the thigh, making it easily accessible and safe for administration. The deltoid muscle (choice C) is not recommended for newborns due to insufficient muscle mass. The dorsogluteal site (choice B) is not recommended for infants due to the proximity to the sciatic nerve. The rectus femoris (choice D) is not typically used for IM injections in newborns.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression.
- B. Polyuria.
- C. Hypotension.
- D. Urticaria.
Correct Answer: A
Rationale: Depression is a known adverse effect of combined oral contraceptives due to the hormonal changes they induce.