Nokea
A primigravida at 40 weeks gestation is in active labor. The nurse notes late decelerations on the fetal monitor tracing. What action should the nurse take first?
- A. Administer oxygen to the mother.
- B. Change the mother's position.
- C. Prepare for immediate delivery.
- D. Discontinue oxytocin infusion.
Correct Answer: D
Rationale: Late decelerations on the fetal monitor tracing indicate a potential uteroplacental insufficiency, which could be caused by decreased oxygen supply to the fetus. One common cause of late decelerations is uterine hyperstimulation due to excessive use of oxytocin. By discontinuing the oxytocin infusion, the nurse can help alleviate the stress on the fetus and decrease the likelihood of further late decelerations. This action should be prioritized before other interventions such as changing the mother's position or administering oxygen. Immediate delivery may be necessary if the fetus continues to show signs of distress despite discontinuing the oxytocin infusion.
You may also like to solve these questions
A nurse involves well-being in her definition of health. What will the primary concern or focus of the nurse when she provides care to a family confronting the imminent death of a family member?
- A. Reinforcing the need for the whole family to adapt to the impending death.
- B. Sharing the nurse's knowledge on the client's symptoms of grief
- C. Discussing the perceived meaning of life with the family
- D. Administering pain medication so that the client can be kept comfortable
Correct Answer: A
Rationale: When a nurse involves well-being in her definition of health, it indicates a holistic approach that considers not only physical health but also emotional, mental, and social aspects of well-being. In the context of a family confronting the imminent death of a family member, the primary concern of the nurse would be to focus on reinforcing the need for the whole family to adapt to the impending death. This involves providing emotional support, facilitating communication, addressing coping mechanisms, and assisting the family in coming to terms with the situation. By emphasizing the importance of the whole family adapting to the imminent death, the nurse can help promote holistic well-being for the family during this challenging time.
The patient refuses to take the medication because it causes diarrhea. Nurse Parker explains the action of the drug but the patient vehemently refuses the medication. What should be the INITIAL action of the nurse?
- A. Discuss with a family member the need for the patient to take the medication.
- B. Document the patient 's refusa l to take the medication.
- C. Notify the physician of the patient 's refusal to take the medication.
- D. Explain again to the patient the consequences of refusing to take the medication.
Correct Answer: C
Rationale: The initial action the nurse should take when faced with a situation where a patient refuses to take medication after education and explanation is to notify the physician. The physician may need to be informed so they can reassess the medication and potentially explore alternative options or make adjustments based on the patient's concerns and preferences. It is important for medical decisions to be made in collaboration with the healthcare team to ensure the best care for the patient. Consulting the physician also helps in avoiding any potential negative outcomes resulting from the patient's refusal to take the prescribed medication. Once the physician is aware, further actions can be discussed and implemented to address the patient's concerns.
A patient presents with delayed puberty, short stature, and a childlike appearance. Laboratory tests reveal low levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1). Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Growth hormone deficiency
Correct Answer: D
Rationale: The patient mentioned in the scenario presents with delayed puberty, short stature, and a childlike appearance. These symptoms are indicative of growth hormone deficiency (GHD). GHD is a condition where the pituitary gland does not produce enough growth hormone, which is crucial for normal growth and development.
The patient asked Nurse Vera when is the best time to visit the clinic for her 1st prenatal care. Which should be the APPROPRIATE answer of the nurse?
- A. Second trimester
- B. Third trimester
- C. Before delivery
- D. First trimester
Correct Answer: D
Rationale: The best time to visit the clinic for the first prenatal care is during the first trimester of pregnancy, ideally before the 12th week. This is because early prenatal care is crucial for monitoring the health of both the mother and the developing baby, identifying any risk factors or complications early on, and initiating important interventions such as prenatal vitamins and screenings. By starting prenatal care early in the first trimester, potential issues can be identified and addressed promptly, leading to better pregnancy outcomes. It is important for pregnant women to seek early prenatal care to ensure a healthy pregnancy and delivery.
A patient with osteoarthritis of the hip undergoes surgical intervention with a total hip arthroplasty (THA). Which postoperative complication should the healthcare team monitor for in the immediate postoperative period?
- A. Deep vein thrombosis (DVT)
- B. Delayed wound healing
- C. Pulmonary embolism
- D. Prosthetic joint infection
Correct Answer: A
Rationale: Following total hip arthroplasty (THA), patients are at an increased risk of developing deep vein thrombosis (DVT) due to factors such as immobility, surgery-related vascular damage, and hypercoagulability. DVT refers to the formation of blood clots in the deep veins, typically in the lower extremities. These clots can break loose and travel to the lungs, causing a potentially life-threatening condition called pulmonary embolism (PE). Therefore, monitoring for signs and symptoms of DVT is crucial in the immediate postoperative period to promptly detect and prevent the development of complications such as PE. Common signs of DVT include leg swelling, pain, warmth, and redness. Additionally, healthcare providers may employ preventive measures such as early ambulation, compression stockings, and anticoagulant therapy to reduce the risk of DVT post-THA surgery.