Nokea
A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Uterine hyperstimulation
- C. Pelvic outlet obstruction
- D. Maternal exhaustion
Correct Answer: B
Rationale: Uterine hyperstimulation is a condition in which the uterus contracts too frequently or too intensely, leading to decreased blood flow and oxygenation to the placenta. This can result in maternal fatigue and decreased fetal oxygenation due to the lack of sufficient rest intervals between contractions. Uterine hyperstimulation can be caused by factors such as the use of synthetic oxytocin (Pitocin) to induce or augment labor, uterine abnormalities, or maternal conditions like pre-eclampsia. It is important for the nurse to assess for uterine hyperstimulation in a woman experiencing frequent and intense contractions to intervene promptly and prevent adverse outcomes for both the mother and the baby.
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In instilling the eye drops you have to tilt the back slightly Claudia's head. Which of the following is the RATIONALE for this nursing action?
- A. To prevent any spill from the eye during the procedure
- B. To keep any debris away from the lacrimal duct
- C. To facilitate the procedure
- D. To reach the conjunctival sac easily
Correct Answer: D
Rationale: Tipping Claudia's head back slightly helps in reaching the conjunctival sac easily. The conjunctival sac is a small space between the lower eyelid and the eye itself where eye drops are typically administered. Tilting the head back allows for better access to this area, ensuring the eye drops are delivered accurately and effectively into the eye.
A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
- A. Perform a pelvic exam to assess for CPD.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Prepare for immediate instrumental delivery.
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
During a support group meeting, Nurse Donato, in a teasing manner, has made several provocative remarks about your appearance and behavior as a group leader. Select your MOST appropriate response.
- A. "Donato, see me after this meeting"
- B. "Donato, you are excused from the group"
- C. "What do you think Donato is trying to tell us?"
- D. "Donato, what are you saying is inappropriate"
Correct Answer: D
Rationale: Choosing option D, "Donato, what you are saying is inappropriate," is the most appropriate response in this situation. It directly addresses Nurse Donato's behavior without escalating the situation or being overly confrontational. By calmly pointing out that the remarks are inappropriate, you are setting a boundary and letting Nurse Donato know that such behavior is not acceptable in a professional setting. This response also signals to the rest of the group that you are aware of the inappropriate comments and are taking action to address them. It is important to address such behavior professionally and assertively to maintain a respectful and supportive environment during the support group meeting.
In planning for Sonny's oxygen therapy, the nurse should consider which of the following, EXCEPT
- A. need for a humidifier.
- B. length of tubing .
- C. determine the age of Excel.
- D. manner of administering oxygen, continuous or intermittent.
Correct Answer: C
Rationale: The nurse does not need to determine the age of Excel when planning for Sonny's oxygen therapy. This information is irrelevant to the specific care requirements of Sonny's oxygen therapy. Sonny's age, medical history, respiratory status, and oxygen needs are the key considerations in planning for his oxygen therapy. The nurse should focus on factors such as the need for a humidifier, length of tubing, and the manner of administering oxygen (continuous or intermittent) to ensure effective and safe delivery of oxygen therapy to Sonny.
A patient is prescribed a nonsteroidal anti-inflammatory drug (NSAID) for the management of pain. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypotension
- B. Hyperkalemia
- C. Gastrointestinal bleeding
- D. Hyperglycemia
Correct Answer: C
Rationale: NSAIDs are commonly known to increase the risk of gastrointestinal adverse effects, including gastritis, ulcers, and gastrointestinal bleeding. This risk is due to the inhibition of prostaglandin synthesis, which plays a protective role in the gastrointestinal mucosa. Gastrointestinal bleeding can manifest as symptoms such as black, tarry stools, vomiting blood, or abdominal pain. Therefore, it is crucial for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding while taking NSAIDs to prevent potentially serious complications. Hypotension, hyperkalemia, and hyperglycemia are not commonly associated with NSAIDs use, making them less likely adverse effects to monitor for in this scenario.