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An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
- A. Place the infant in a knee-chest position.
- B. Administer morphine sulfate.
- C. Start intravenous fluids.
- D. Provide 100% oxygen by face mask.
Correct Answer: A
Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.
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At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
- A. Round ligament strain.
- B. Chorioamnionitis.
- C. Abruptio placenta.
- D. Viral infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?
- A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
- B. Suggest placing the iron drops in the orange juice and then feeding the infant.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Give the mother positive feedback about the way she administered the medication.
Correct Answer: D
Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver.
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?
- A. 45
- B. 15 mL
- C. 4
- D. 13
Correct Answer: D
Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
- A. Palpate the client's bladder.
- B. Check the pH of the vaginal fluid.
- C. Review the fetal heart rate pattern.
- D. Determine cervical dilation.
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
- A. 150 mL/hour
- B. 250 mL/hour
- C. 50 mL/hour
- D. 275 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. In this case, with 20 grams of magnesium sulfate in 500 mL of solution, there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. This calculation ensures the correct dose is delivered within the specified time frame.