Nokea
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
The FIRST action the nurse should take is
- A. turn the mother on her right side, increase the intravenous flow rate, and call the physician.
- B. turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
- C. call the physician, and make preparations for an immediate emergency cesarean section.
- D. position the mother in Trendelenburg's position, administer oxygen, and force fluids.
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
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The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. I will note an increase in fetal movement.
- B. I may feel a gush of fluid run down my legs.
- C. I may see some blood in my vaginal discharge.
- D. I may experience a low backache.
Correct Answer: A
Rationale: Fetal movement decreases at labor onset due to limited space; expecting an increase indicates misunderstanding. Options B, C, and D are correct labor signs.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for a client with a history of ulcerative colitis.
- A. Which laboratory finding is most concerning for a client with ulcerative colitis?
- B. Hemoglobin of 10.5 g/dL.
- C. White blood cell count of 15,000/mm³.
- D. Serum potassium of 3.8 mEq/L.
- E. Albumin of 3.0 g/dL.
Correct Answer: B
Rationale: A white blood cell count of 15,000/mm³ suggests infection or severe inflammation in ulcerative colitis, requiring immediate attention. Low hemoglobin and albumin are common, and normal potassium is unremarkable.
The nurse is preparing a client with a severe case of inflamed hemorrhoids for a rectal examination by the physician. What is the best position to place her in on the examination table?
- A. Dorsal recumbent
- B. Knee-chest
- C. Sims'
- D. Lithotomy
Correct Answer: B
Rationale: The knee-chest position provides optimal exposure for rectal examination, minimizing discomfort with inflamed hemorrhoids.
A 21-year-old woman at 16 -weeks gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by this Test ?
- A. Tetralogy of Fallot.
- B. Talipes equinovarus.
- C. Hemolytic disease of the newborn.
- D. Cleft lip and palate.
Correct Answer: C
Rationale: maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis