Nokea
How should a nurse educate a mother about kangaroo care for her preterm infant?
- A. Encourage frequent visits to the NICU
- B. Educate about skin-to-skin contact benefits
- C. Explain the importance of bonding
- D. Teach the mother about safe handling of the newborn
Correct Answer: B
Rationale: Kangaroo care promotes bonding and regulates temperature for preterm infants.
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The nurse is assessing a pregnant client with hyperemesis gravidarum. What is the priority nursing action?
- A. Monitor for dehydration and electrolyte imbalances.
- B. Encourage the client to eat small, frequent meals.
- C. Provide antiemetic medication as prescribed.
- D. Assess for fetal growth restriction.
Correct Answer: A
Rationale: Monitoring for dehydration and electrolyte imbalances is critical due to the risk of complications from persistent vomiting.
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.
Platypelloid pelvis
- A. Places the client as risk for dystocia
- B. Has an increased probability of cesarean section
- C. Has a flat shape that may impede fetal descent
- D. A Gynecoid pelvis is roomy and ideal for vaginal birth. An Anthropoid pelvis has an oval shape, and an android pelvis is heart shape.
Correct Answer: A
Rationale: A platypelloid pelvis is characterized by a flat shape with a shortened anteroposterior diameter, which can impede fetal descent during labor. This pelvic type is associated with an increased risk of dystocia, which is difficulty in childbirth due to inadequate progress of labor. The flat shape of the pelvis may lead to improper positioning of the baby, making it challenging for the fetus to navigate through the birth canal. This can result in prolonged labor, increased risk of birth injuries, and potential complications for both the mother and the baby. In some cases, it may necessitate interventions such as labor induction or cesarean delivery to ensure a safe outcome for the mother and the baby.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.