Nokea
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color." Client also reports contractions began about 4 hr ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also, states were diagnosed with gestational diabetes at 28 weeks of gestation.
Vital Signs
2000:
Temperature 36.7° C (98.1° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
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A nurse is reporting a client's laboratory test to the provider to obtain a prescription for warfarin.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.
A nurse is planning care for a client who was receiving continuous internal tube feeding through an open system.
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
A nurse is providing teaching about home safety to an adult child of an older adult client who is postoperative following knee replacement surgery.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
A nurse is preparing to initiate intravenous fluids via pump for a client.
which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Ensure the IV tubing is primed and free of air bubbles before connecting it to the client
- C. Position the IV pump below the level of the client's heart to prevent rapid infusion
- D. Select a catheter gauge of 12 to ensure adequate fluid flow
Correct Answer: B
Rationale: The nurse should choose option B: Ensure the IV tubing is primed and free of air bubbles before connecting it to the client. This is crucial to prevent air embolism, which can be life-threatening. Priming the tubing ensures that only fluid is infused into the client's bloodstream. Air bubbles can travel to the heart and lungs, causing blockages and impairing circulation. Positioning the IV pump below the client's heart (option C) is incorrect as it can lead to rapid infusion and potential complications. Selecting a catheter gauge of 12 (option D) is not always necessary; the appropriate gauge depends on the client's condition and prescribed therapy. Obtaining a surge protector (option A) is irrelevant to the safe administration of IV therapy.
A community health nurse is working with a group of clients.
Which task should the nurse perform to practice distributive justice?
- A. Ensuring that a client who is homeless receives preventative medical care
- B. Allocating community resources fairly among all clients in need.
- C. Prioritizing care for clients based on medical necessity rather than financial status.
- D. Advocating for equal access to healthcare services for underserved populations.
- E. Developing programs that address social determinants of health to reduce disparities.
Correct Answer: E
Rationale: The correct answer is E because developing programs that address social determinants of health to reduce disparities aligns with the principle of distributive justice, which focuses on fair distribution of resources to reduce inequalities. By addressing social determinants of health, such as income inequality or access to education, the nurse is working towards creating equal opportunities for all individuals to achieve good health outcomes.
Choices A, B, C, and D do not directly address the root causes of health disparities and inequality. Option A focuses on providing care to a specific individual rather than addressing systemic issues. Option B talks about allocating resources fairly but lacks the focus on addressing social determinants. Option C mentions prioritizing care based on medical necessity, which may not necessarily target disparities. Option D discusses advocating for equal access, but it does not specifically address the underlying social determinants that contribute to inequalities.