Foundations and Adult Health Nursing Test Bank

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A woman in active labor is receiving intravenous oxytocin for labor augmentation. What nursing intervention is essential to prevent oxytocin-induced uterine hyperstimulation?

  • A. Monitor maternal vital signs every 2 hours.
  • B. Increase the oxytocin infusion rate gradually.
  • C. Administer intravenous fluids rapidly.
  • D. Encourage the mother to ambulate regularly.
Correct Answer: B

Rationale: When a woman in active labor is receiving intravenous oxytocin for labor augmentation, it is essential to increase the oxytocin infusion rate gradually to prevent oxytocin-induced uterine hyperstimulation. Uterine hyperstimulation can lead to complications such as fetal distress, uterine rupture, and postpartum hemorrhage. By increasing the oxytocin infusion rate gradually, the uterus has more time to adapt to the medication and reduces the risk of hyperstimulation. It is crucial for the healthcare provider to carefully monitor the woman's response to oxytocin and adjust the infusion rate as needed to ensure safe and effective labor augmentation. Monitoring for signs of uterine hyperstimulation, such as persistent contractions close together or excessive uterine activity, is crucial in preventing complications and ensuring the well-being of both the mother and baby.

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Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is _____.

  • A. increasing pulse and decreasing blood pressure
  • B. altered mental status and level of consciousness
  • C. dizziness and increasing respiratory rate
  • D. Cool, clammy skin, and pale mucous membranes
Correct Answer: A

Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.

Nurse Juvy's assessment reveals the following: Heart Rate is 110 beats per minute, has a vigorous cry, moves actively and with good flexion, normal skin color and bluish extremities. What would be thd APGAR score of Baby Sharon?

  • A. 7 Points
  • B. 5 Points
  • C. 10 Points
  • D. 9 Points
Correct Answer: B

Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.

A patient with a history of chronic kidney disease is prescribed erythropoietin-stimulating agents (ESAs) for anemia management. Which parameter should the nurse monitor closely during ESA therapy?

  • A. Serum potassium levels
  • B. Hemoglobin levels
  • C. Serum creatinine levels
  • D. White blood cell count
Correct Answer: B

Rationale: When a patient with chronic kidney disease is prescribed erythropoietin-stimulating agents (ESAs) for anemia management, the parameter that should be monitored closely by the nurse is the hemoglobin levels. Hemoglobin levels indicate the patient's response to ESA therapy and are essential in assessing the effectiveness of the treatment in addressing anemia. Monitoring hemoglobin levels helps ensure that the patient's anemia is controlled within the target range to avoid both the risks of under-treatment (resulting in persistent anemia) and over-treatment (increased risk of adverse outcomes such as hypertension, stroke, or cardiovascular events).

The client asks the nurse about using decongestant nasal sprays. Which of the following statements by the nurse is CORRECT regarding its use?

  • A. "Nasal sprays should be use sparingly because they can exacerbate a cough"
  • B. "It would take several days of using nasal sprays before any effect on congestion is noted"
  • C. "Nasal sprays should not be used formore than three days because it can worsen congestion"
  • D. "They should be used along with corticosteroid nasal sprays for maximum benefit"
Correct Answer: C

Rationale: The correct statement regarding the use of decongestant nasal sprays is that "Nasal sprays should not be used for more than three days because it can worsen congestion." Prolonged use of decongestant nasal sprays can lead to rebound congestion, where the congestion worsens with extended use. Therefore, it is important to limit the use of these sprays to avoid this side effect. It is recommended to use decongestant nasal sprays for no longer than three consecutive days.

The last and necessary part of the activity is _______.

  • A. informing the students their next day 's assignment
  • B. the joke portion for good vibes
  • C. evaluation so that future. but similar activities can be improved
  • D. after care of the venue, an earlier reminder by the Head Nurse
Correct Answer: C

Rationale: The last and necessary part of any activity should involve an evaluation process. By evaluating the activity, the organizers can gather feedback on what worked well and what areas need improvement. This feedback is crucial for enhancing future activities that are similar in nature. It allows for reflections on the effectiveness of the activity, identifies strengths and weaknesses, and helps in making necessary adjustments for better outcomes in the future. Overall, evaluation ensures continuous improvement and development in organizing successful activities.

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