Nokea
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
- A. I can administer oxytocin 4 hours after the insertion of the medication
- B. You will need a full bladder prior to the insertion of the medication
- C. Remain in a side-lying position for 15 minutes after the medication is inserted
- D. An antacid will be given 20 minutes prior to the insertion of the medication
Correct Answer: C
Rationale: The correct answer is C: Remain in a side-lying position for 15 minutes after the medication is inserted. This instruction is important because misoprostol can cause uterine contractions leading to potential discomfort or cramping. By remaining in a side-lying position, the client can help the medication remain in the desired location near the cervix, enhancing its effectiveness. This position also helps reduce the risk of the medication leaking out prematurely and ensures optimal absorption.
Choice A is incorrect because oxytocin is not typically administered shortly after misoprostol due to the potential for excessive uterine stimulation. Choice B is incorrect as a full bladder is not necessary for the insertion of misoprostol. Choice D is incorrect as an antacid is not typically required prior to the insertion of misoprostol.
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Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got 'a shot in his leg.' Which response by the nurse is most appropriate?
- A. Vitamin K promotes bone and muscle growth.
- B. Vitamin K helps the baby digest milk.
- C. Vitamin K helps stabilize the baby's blood sugar.
- D. Vitamin K is used to prevent bleeding.
Correct Answer: D
Rationale: The correct answer is D: Vitamin K is used to prevent bleeding. Shortly after birth, newborns have low levels of Vitamin K, which is essential for blood clotting. Administering phytonadione helps prevent a rare but serious condition called Vitamin K deficiency bleeding. Option A is incorrect as Vitamin K primarily supports blood clotting, not bone and muscle growth. Option B is incorrect as Vitamin K does not aid in digestion. Option C is incorrect as Vitamin K does not directly affect blood sugar stabilization.
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
- A. Let me help you into a comfortable pushing position so you can begin bearing down.
- B. I am going to call the doctor to get a prescription for medication to ripen your cervix.
- C. I will give you some IV pain medicine to strengthen your contractions.
- D. Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client about the provider inserting an intrauterine pressure catheter to monitor contraction strength. This is appropriate because lack of cervical change in active labor could indicate inadequate contractions. Monitoring contraction strength with an intrauterine pressure catheter can help determine if the contractions are effective in progressing labor. It allows for more accurate assessment and timely interventions if needed.
Choice A is incorrect because pushing without adequate cervical dilation can lead to complications. Choice B is incorrect as medication to ripen the cervix is not indicated in this scenario. Choice C is incorrect as IV pain medicine does not address the issue of inadequate cervical change.
A nurse is caring for a 4-year-old child diagnosed with leukemia who is admitted with myelosuppression.
- A. "Provide a diet high in carbohydrates."'
- B. "Monitor rectal temperature every 4 hr."'
- C. "Use lemon or glycerin swabs for oral care."'
- D. "Inspect the skin daily for lesions."'
Correct Answer: D
Rationale: The correct answer is D: "Inspect the skin daily for lesions." This is important because myelosuppression can lead to decreased platelets, increasing the risk of skin lesions and bleeding. Monitoring the skin daily can help detect any lesions early and prevent complications.
A: Providing a high-carbohydrate diet is not directly related to managing myelosuppression.
B: Monitoring rectal temperature is important but not directly related to skin lesion detection.
C: Using lemon or glycerin swabs for oral care is important for mucositis, not skin lesions.
When planning for the care of an infant experiencing neonatal abstinence syndrome, which nursing assessment is most important?
- A. The mother's ability to provide a safe environment
- B. The extent of addiction of the mother
- C. The mother's ability to obtain treatment
- D. The severity of the infant's withdrawal
Correct Answer: A
Rationale: The correct answer is A: The mother's ability to provide a safe environment. This is crucial because infants with neonatal abstinence syndrome require a stable and safe environment for optimal care and recovery. Assessing the mother's ability to provide this environment helps ensure the infant's safety and well-being. Choice B is incorrect because the extent of the mother's addiction, while important, does not directly impact the immediate care of the infant. Choice C is incorrect as the focus should be on the current situation and care of the infant rather than the mother obtaining treatment. Choice D is incorrect as the severity of the infant's withdrawal, though important, is not the most critical assessment in planning care.
A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Reports increased urinary output
- B. Diaphoresis
- C. Reports blurred vision
- D. Shallow respirations
Correct Answer: A
Rationale: The correct answer is A: Reports increased urinary output. In hyperglycemia, the body tries to eliminate excess glucose through urine, leading to increased urinary output. This is known as osmotic diuresis. Diaphoresis (B) is sweating, which is not typically associated with hyperglycemia. Blurred vision (C) is a symptom of prolonged hyperglycemia affecting the eyes but not an immediate finding. Shallow respirations (D) are not directly related to hyperglycemia.