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 because the client is Rh-negative and has undergone an invasive procedure that could potentially lead to mixing of maternal and fetal blood, increasing the risk of Rh sensitization. Administering Rh(0) Immune globulin helps prevent this sensitization by destroying any fetal Rh-positive red blood cells that may have entered the maternal circulation. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is relevant but not as urgent as administering Rh(0) Immune globulin. Monitoring the fetal heart rate (D) is also important, but preventing Rh sensitization takes precedence in this scenario.
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The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and ---------------------------------
- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: The correct answer is A,B. First, providing education on medications is crucial to ensure the adolescent understands the prescribed treatment. This empowers them to adhere to the regimen, promoting better health outcomes. Second, administering ceftriaxone aligns with the provider's prescription and is a direct action the nurse must take to carry out the treatment plan. Choices C, D, E, F, and G are incorrect because administering metronidazole and educating on condom use (C) is not the immediate priority. Administering metronidazole is not mentioned in the provider's prescriptions, so it is not the first step. Choices D, E, F, and G are irrelevant and not related to the provider's prescriptions or the adolescent's care.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding can indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. Preeclampsia poses risks to both the mother and the baby, so prompt reporting to the provider is crucial for timely intervention. Varicose veins in the calves (B) are common in pregnancy due to increased pressure on the veins but do not require immediate provider notification. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and is not typically concerning unless it worsens significantly. Hyperpigmentation of the cheeks (D) is a common benign finding known as melasma and does not require immediate reporting unless accompanied by other concerning symptoms.
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.
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 newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: The correct answer is A: Decrease the lighting levels in the nursery. Neonatal abstinence syndrome causes sensitivity to stimuli, including light. By decreasing lighting levels, the nurse can help reduce overstimulation and promote a calm environment for the newborn. This can aid in soothing the baby and decreasing symptoms associated with the syndrome.
Choice B is incorrect because wrapping the newborn loosely in a blanket may not directly address the sensitivity to light and other stimuli. Choice C, providing frequent stimulation, would likely exacerbate the symptoms of neonatal abstinence syndrome due to the increased sensory input. Choice D, encouraging frequent eye contact during feedings, could also lead to overstimulation for the newborn.