Nokea
The nurse is providing education on a medical abortion. How would she describe the action of the medications?
- A. Medications thicken the lining of the uterus and decrease uterine contractions.
- B. Medications stop the fetal heart and induce contractions.
- C. Medications soften the cervix, cause uterine lining necrosis, and induce contractions.
- D. Medications thicken the cervix and the uterine lining.
Correct Answer: C
Rationale: Medications used in a medical abortion typically consist of a combination of Mifepristone and Misoprostol. The action of these medications involves three main effects: softening the cervix to facilitate the expulsion of the pregnancy tissue, causing necrosis of the uterine lining to disrupt the pregnancy, and inducing contractions to expel the contents of the uterus. This process is different from a surgical abortion, which involves a procedure to remove the pregnancy tissue from the uterus.
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A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Maternal heart rate of 85 beats/minute.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, which may signify fetal distress and requires immediate action.
A person is admitted to the antepartum floor for hypertension. The person is Hispanic and speaks fluent English. They tell the nurse they have been seeing a curandero, or traditional healer, for the past several years. What is the best initial response from the nurse?
- A. Ask the patient for a list of all herbs, plants, and special diets they are currently taking.
- B. Educate the person on why adherence to a Western medical treatment plan is better for their health.
- C. Inform the person that the treatment they have been receiving from the curandero is not evidence based.
- D. Tell the person that they are not considering the health of their baby by using these traditions.
Correct Answer: A
Rationale: Understanding the patient's use of traditional healing practices ensures safe integration with Western medicine.
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Assist the client to breathe into a paper bag.
- C. Have the client tuck her chin to her chest.
- D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Correct Answer: A
Rationale: The client is exhibiting signs of hyperventilation, which can occur as a result of rapid breathing techniques such as pattern-paced breathing during labor. Administering oxygen via nasal cannula can help the client rebalance her oxygen and carbon dioxide levels, which will alleviate the lightheadedness and tingling sensations she is experiencing. Oxygen therapy is the appropriate intervention for respiratory alkalosis caused by hyperventilation. Assisting the client to breathe into a paper bag or instructing her to increase her respiratory rate would exacerbate the hyperventilation and should be avoided. Tucking her chin to her chest is not an appropriate intervention in this situation.
On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.