Nokea
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2 at <40%
- B. Maintain O2 at >40%
- C. Give moist O2 at >40%
- D. Maintain on 100% O2
Correct Answer: A
Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.
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The client with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should teach the client to:
- A. Take the medication with meals.
- B. Report blurred vision immediately.
- C. Use the inhaler every 2 hours as needed.
- D. Avoid drinking water after use.
Correct Answer: B
Rationale: Ipratropium, an anticholinergic bronchodilator, can cause blurred vision, a side effect requiring immediate reporting. It is not taken with meals, is used every 6–8 hours, and water restriction is unnecessary.
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
- A. Below the umbilicus toward left side of mother's abdomen
- B. Below the umbilicus toward right side of mother's abdomen
- C. At the umbilicus
- D. Above the umbilicus to the left side of mother's abdomen
Correct Answer: A
Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
- A. A large gush of clear fluid from the vagina
- B. Systolic hypertension
- C. Abdominal rigidity
- D. Increased fetal movements
Correct Answer: C
Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Length of her labor
- B. Type of episiotomy
- C. Amount of IV fluid to be infused
- D. Character of the fundus
Correct Answer: D
Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.