Nokea
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second using a 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B
Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.
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The nurse is educating a client about preterm labor. What symptom should the client report immediately?
- A. Frequent urination.
- B. Lower back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.
The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
The nurse discusses treatment for side effects of perimenopause. What education should be provided?
- A. Menopausal hormone therapy can decrease symptoms of menopause.
- B. Hot flashes are normal, and no one should need treatment for this symptom.
- C. Medications to decrease estrogen can help with insomnia.
- D. Depression is normal, so no treatment is needed.
Correct Answer: A
Rationale: