Nokea
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
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A client asks a nurse working in a dental office what type of drug the dentist uses to provide anesthesia during the extraction of the client's wisdom teeth. The dentist uses an anesthetic gas, also known as laughing gas. This agent is:
- A. nitrous oxide.
- B. nitrogen.
- C. nitric oxide.
- D. nitrogen dioxide.
Correct Answer: A
Rationale: Nitrous oxide produces analgesia and is often used for minor surgery and dental procedures that do not require loss of consciousness. It can also produce a mild euphoria in some clients.
The new nurse asks the experienced nurse why the first dose of the MMR vaccine is normally given at 12 to 15 months of age and not earlier, except with international travel. Which explanation by the experienced nurse is correct?
- A. Giving the first dose of the vaccine at 12 to 15 months of age allows the correct interval before the next booster at age 12 years.
- B. A live virus is being given; the chance of measles, mumps, or rubella developing is much higher if given at an earlier age.
- C. A first dose at this age provides passive immunity and decreases the incidence of a child developing any of the diseases.
- D. If given earlier, the vaccine may neutralize the passive immunity to measles from the child's mother and no immunity may result.
Correct Answer: D
Rationale: A: The second dose of the MMR vaccine can be given earlier, provided that at least 4 weeks has elapsed since the first dose. However, a second dose is usually not given earlier because sufficient immunity is usually present. B: The chance of developing only measles is greater if the vaccine is given at a younger age because the vaccine may neutralize the passive antibodies. C: The MMR provides active (not passive) immunity. D: Because the MMR vaccine is a live virus, a person develops a mild form of the diseases after administration, stimulating the body to develop immunity. The passively acquired antibodies to measles can interfere with the child's immune response to the vaccine, and no immunity may result.
A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:
- A. is normal if the level is 4.0 to 5.5 mg/dl.
- B. can be elevated with increased protein intake.
- C. is a better indicator of renal function than the BUN.
- D. reflects the fluid volume status of a person.
Correct Answer: C
Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN, which can be affected by diet and hydration status.
The nurse is concerned that the adolescent may be developing a side effect of methotrexate. Which test or exam results should the nurse review prior to administration?
- A. Folic acid level
- B. Serum electrolytes
- C. Complete blood count
- D. Activated partial prothrombin time
Correct Answer: C
Rationale: A: Although methotrexate is a folic acid antagonist, it does not alter serum levels. B: Methotrexate has no effect on electrolytes. C: An adverse effect of methotrexate (Trexall) is aplastic anemia; thus, the nurse should review the CBC results before administration. D: Methotrexate has no effect on coagulation.
The nurse prepares to administer naloxone 0.4 mg IV to the client experiencing respiratory depression. Naloxone is supplied in a 1-mg/mL vial. How many milliliters should the nurse administer?
Correct Answer: 0.4
Rationale: Use a proportion formula to calculate the correct amount. Multiply the extremes and then the means and solve for X. 1 mg: 1 mL :: 0.4 mg: X mL; X = 0.4 mL. The nurse should administer 0.4 mL of naloxone (Narcan).