Nokea
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Correct Answer: C (Fetal anemia)
Rationale: Fetal anemia can lead to decreased oxygen delivery to the fetus, causing fetal bradycardia. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the heart working harder to compensate for the decreased oxygen levels, leading to a lower fetal heart rate.
Summary of Incorrect Choices:
A: Maternal hypoglycemia - Unlikely to cause fetal bradycardia directly.
B: Chorioamnionitis - Typically presents with maternal fever and tachycardia, not fetal bradycardia.
D: Maternal fever - Can cause fetal tachycardia, not bradycardia.
You may also like to solve these questions
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Maintain calorie intake at 1,500 per day
- B. Provide a low-protein, high-carbohydrate diet.
- C. Keep a calorie count for foods and beverages.
- D. Schedule meals at 6-hr intervals
Correct Answer: C
Rationale: The correct answer is C: Keep a calorie count for foods and beverages. For a client with major burn injuries, accurate monitoring of calorie intake is crucial to support nutritional requirements for wound healing and metabolic demands. This intervention allows the nurse to adjust the diet as needed to meet the client's energy needs. Choice A is incorrect as calorie intake requirements may vary based on individual needs. Choice B is incorrect as a high-protein diet is essential for wound healing in burn patients. Choice D is incorrect as frequent, smaller meals are typically recommended for burn patients to support healing and prevent muscle breakdown.
A nurse is assessing a client who has a possible right pneumothorax. Which of the following findings should the nurse expect?
- A. Reduced right-sided breath sounds
- B. Intercostal retractions
- C. High-pitched stridor
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. In a right pneumothorax, air enters the pleural space, causing lung collapse and reduced breath sounds on the affected side. Intercostal retractions (B) occurs in respiratory distress but are not specific to pneumothorax. High-pitched stridor (C) is associated with upper airway obstruction, not pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not pneumothorax.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.