Nokea
The nurse discovers a medication error where a postpartum client received 400 mg of ibuprofen instead of 800 mg. The nurse should:
- A. Monitor the client for adverse effects.
- B. Administer the remaining 400 mg immediately.
- C. Notify the physician and complete an incident report.
- D. Document the dose as administered without reporting.
Correct Answer: C
Rationale: Notifying the physician and filing an incident report ensures patient safety and proper follow-up.
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A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?
- A. Early deceleration pattern.
- B. Sinusoidal pattern.
- C. Variable deceleration pattern.
- D. Late deceleration pattern.
Correct Answer: B
Rationale: Rh sensitization with fetal hydrops and anemia often causes a sinusoidal fetal heart rate pattern due to severe fetal anemia and hypoxia. Early, variable, or late decelerations are less specific to this condition.
After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which of the following?
- A. Dehydration.
- B. Pallor.
- C. Sweating.
- D. Nervousness.
Correct Answer: A
Rationale: Dehydration is a symptom of hyperglycemia.
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.
After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ?
- A. Respiratory anomalies.
- B. Musculoskeletal anomalies.
- C. Cardiovascular anomalies.
- D. Facial anomalies.
Correct Answer: C
Rationale: A single umbilical artery is associated with an increased risk of cardiovascular anomalies, warranting further evaluation.
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
- A. I need to increase my intake of vitamin D.
- B. I should drink at least five glasses of fluid daily.
- C. I need to get an extra 500 calories per day.
- D. I need to make sure I have enough calcium in my diet.
Correct Answer: B
Rationale: Breastfeeding mothers need 8-10 glasses of fluid daily to support milk production, so five glasses is insufficient.