Nokea
A pregnant client at 32 weeks' gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action should the nurse take to support the viability of the fetus?
- A. Insert an intravenous line and begin an infusion at 125 mL per hour.
- B. Administer oxygen to the woman via a face mask at 7 to 10 L per minute.
- C. Position and connect the ultrasound transducer to the external fetal monitor.
- D. Position and connect a spiral electrode to the fetal monitor for internal fetal monitoring.
Correct Answer: C
Rationale: External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in jeopardy. The amount of bleeding described is insufficient to require intravenous fluid replacement. Because fetal distress has not been determined at this time, oxygen administration is premature. Internal monitoring is contraindicated when there is vaginal bleeding, especially in preterm labor.
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While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse should determine that the client is taking the medication to treat which disorder?
- A. Glaucoma
- B. Pyloric stenosis
- C. Renal insufficiency
- D. Urinary frequency and urgency
Correct Answer: D
Rationale: Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.
- A. Uterine irritability
- B. Uterine tenderness
- C. Painless vaginal bleeding
- D. Abdominal and low back pain
- E. Strong and frequent contractions
- F. Nonreassuring fetal heart rate patterns
Correct Answer: A,B,D,F
Rationale: Placental abruption, also referred to as abruptio placentae, is the separation of a normally implanted placenta before the fetus is born. It occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. Manifestations include uterine irritability with frequent low-intensity contractions, uterine tenderness that may be localized to the site of the abruption, aching and dull abdominal and low back pain, painful vaginal bleeding, and a high uterine resting tone identified by the use of an intrauterine pressure catheter. Additional signs include nonreassuring fetal heart rate patterns, signs of hypovolemic shock, and fetal death. Painless vaginal bleeding is a sign of placenta previa.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
- A. Older clients tend to be incontinent.
- B. Older clients are at risk for dehydration.
- C. Depression is a normal part of the aging process.
- D. Age-related skin changes require special monitoring.
- E. Older clients are at risk for complications of immobility.
- F. Confusion and cognitive changes are common findings in the older population.
Correct Answer: B,D,E
Rationale: Older clients are at risk for dehydration and complications related to immobility. Another normal physiological change that occurs during the aging process is loss of skin integrity. Incontinence, depression, confusion, and cognitive changes are not normal parts of the aging process.
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
- A. Changing the toddler's diapers every 2 hours.
- B. Keeping the toddler's genital area open to the air.
- C. Implementing a 3-hour turning schedule for the toddler.
- D. Assessing the toddler's perineal area for redness regularly.
Correct Answer: A
Rationale: The spica cast is often needed to treat developmental hip dysplasia (DDH) or after hip/pelvis surgery. The cast encases the child's trunk and one or both legs while leaving access to the genital. Considering the age of the child, diapers will be in use and will need to be changed at least every 2 hours during the day and 3 to 4 hours during the night to help minimize the effect of urine and feces on the child's diaper area. Exposing the genital and perineal area to the air is an intervention that is implemented to assist in healing damaged skin tissue. Turning the child regularly is appropriate care but has no impact on the major issue of incontinence. Assessment of the skin is necessary but identifies skin breakdown once it has begun.