Nokea
Woman receiving oxytocin (Pitocin) infusion
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
- B. A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
- C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
- D. A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
Correct Answer: D
Rationale: Contractions every 1.5 minutes lasting 95 seconds in transition indicate hyperstimulation, risking fetal distress, so the infusion should be stopped.
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Woman post-spinal anesthesia, pounding headache rated 7/10
A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?
- A. Place a cool cloth on her forehead and dim the room lights.
- B. Prepare to assist with a blood patch procedure.
- C. Increase the rate of her nonadditive IV fluids.
- D. Give the woman IV opioid pain medications.
Correct Answer: B
Rationale: A pounding headache post-spinal anesthesia suggests a spinal headache from cerebrospinal fluid leakage, best treated with a blood patch to seal the dural puncture.
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
During vaginal delivery, newborn's head emerges
During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
- A. The cord is still pulsating.
- B. The cord is intact.
- C. No part of the cord is encircling the baby's neck.
- D. The cord is still attached to the placenta.
Correct Answer: C
Rationale: Checking for a nuchal cord (cord around the neck) is critical to prevent compression, which could reduce blood flow and oxygen to the baby.
Newborn 1 hour after birth, axillary temperature 95.8°F, apical pulse 114 bpm, respiratory rate 60 breaths/minute
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
- A. Hypothermia.
- B. Deficient fluid volume.
- C. Impaired gas exchange.
- D. Risk for infection.
Correct Answer: A
Rationale: The low temperature (95.8°F) indicates hypothermia, a priority due to risks of hypoglycemia, acidosis, and impaired oxygen delivery.
Infant with axillary temperature of 35.9C (96.6F)
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
- A. chart the normal axillary temperature.
- B. recheck the infant's temperature rectally.
- C. place the infant in a radiant warmer.
- D. have the mother breastfeed the infant.
Correct Answer: C
Rationale: The low temperature indicates hypothermia, and placing the infant in a radiant warmer is the priority to stabilize body temperature and prevent complications.