Nokea
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
- A. Elevated central venous pressure and peripheral edema
- B. Dyspnea and jaundice
- C. Hypotension and Hepatomegaly
- D. Decreased peripheral perfusion and rales
Correct Answer: D
Rationale: Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
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A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pancuronium bromide, a neuromuscular blocker, paralyzes muscles to prevent fighting the ventilator, ensuring effective ventilation. Sedatives like midazolam or fentanyl are secondary.
The client with a history of preterm labor is being monitored at 28 weeks gestation. The physician orders betamethasone (Celestone). The rationale for administering betamethasone is to:
- A. Prevent infection
- B. Stimulate labor
- C. Enhance fetal lung maturity
- D. Prevent bleeding
Correct Answer: C
Rationale: Betamethasone a corticosteroid is given to women in preterm labor (24-34 weeks) to enhance fetal lung maturity by promoting surfactant production reducing the risk of respiratory distress syndrome. It does not prevent infection stimulate labor or prevent bleeding.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
- A. Notify physician of nonreassuring FHR pattern.
- B. Turn the client to her left side.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Evaluate to see if the monitor strip is reassuring.
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
- A. Complaints of dyspnea
- B. Edema of face and hands
- C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
- D. Hematocrit 39%
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.