Nokea
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) and monitoring the FHR (D) are important but not the priority immediately post-procedure. Observing for uterine contractions (B) is important but not the priority for an Rh-negative client after amniocentesis.
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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice C) can also dislodge the clot and should be avoided. Applying cold compresses (choice D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1], [0, 1, 0], [0, 0, 0], [0, 0, 1]
Inserting a large bore IV catheter is indicated for rapid fluid resuscitation. Weighing perineal pads helps monitor postpartum hemorrhage. Assessing cervical dilation and administering methotrexate are not appropriate in this scenario.
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: The correct answer is A: Depression. Combined oral contraceptives can lead to mood changes, including depression, as a potential adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor and address any mental health concerns. Polyuria (increased urination) is not a common adverse effect of combined oral contraceptives. Hypotension (low blood pressure) is not typically associated with this medication. Urticaria (hives) is more commonly seen with allergic reactions rather than as a side effect of oral contraceptives.
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is Indicated or contraindicated for the newborn
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer: B
Rationale: [0, 1, 0, 0]
Assess for grasp reflex in the affected extremity is the correct answer. This action is indicated as it allows the nurse to evaluate neurological function and muscle strength in the affected arm without causing harm. Educating parents to begin range of motion exercises after 1 week (A) is contraindicated as it may exacerbate injury or delay healing. Immobilizing the arm across the abdomen (C) is also contraindicated as it can restrict movement and hinder recovery. Instructing parents to limit physical handling for 2 weeks (D) is not the best option as it may not provide the necessary assessment and treatment for the newborn's condition.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.