Nokea
The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.
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Which of the following findings would indicate
- A. Reversal of a tubal ligation is easily done, with a an infant who may be considered preterm?
- B. Labia minora are larger than labia majora
- C. After this procedure, I must abstain from inter-
- D. Plantar creases cover two-thirds of foot
Correct Answer: D
Rationale: The correct answer is D because plantar creases covering two-thirds of the foot is a typical finding in Down syndrome. This is known as the Sandal gap sign, which is a characteristic feature of Down syndrome. The other choices are incorrect because: A is not related to any specific medical condition, B describes a normal anatomical variation, and C is incomplete and does not provide enough information to determine its relevance.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used to induce ovulation in women experiencing infertility. Breast tenderness is a common adverse effect due to the hormonal changes caused by the medication. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly associated with ototoxic medications, urinary frequency may be seen with diuretics, and chills are usually a symptom of infections or fevers.
The primigravida is admitted to the birthing and labor unit, but
- A. The initial response from the nurse will be to:
- B. Take health history
- C. Perform vaginal exam
- D. Review prenatal record
Correct Answer: B
Rationale: The correct answer is B: Take health history. This is the initial response because obtaining the patient's health history provides crucial information about the primigravida's medical background, current health status, any complications, and helps in assessing the risk factors for labor and delivery. This information guides the nurse in providing appropriate care and making informed decisions during the labor process.
Choice A (The initial response from the nurse will be to) is vague and not specific enough to address the immediate needs of the patient.
Choice C (Perform vaginal exam) is not appropriate as the first action because it can be invasive and should only be performed after obtaining the health history to determine the necessity and timing of the exam.
Choice D (Review prenatal record) is important but should come after taking the health history to supplement the information obtained and provide a comprehensive understanding of the patient's pregnancy course.
A nurse is caring for a client who is receiving Iv magnesium sulfate which of the following medication should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine (Adalat)
- B. Pyridoxine (vitamin B)
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. In cases of magnesium sulfate toxicity, calcium gluconate is administered as an antidote due to its ability to counteract the effects of magnesium. Magnesium and calcium ions have an antagonistic relationship in the body, so administering calcium gluconate can help reverse the toxic effects of magnesium. Nifedipine (A), Pyridoxine (B), and Ferrous sulfate (C) do not have a direct antidote effect on magnesium toxicity and are not indicated for this purpose.
Why would FAM not be appropriate for the nurse to recommend to a perimenopausal person?
- A. At that age, people do not have intercourse on a regular basis.
- B. They are married and do not need contraception.
- C. They have irregular menstrual periods.
- D. Pregnancy is not a concern when a person is perimenopausal.
Correct Answer: C
Rationale: The correct answer is C because perimenopausal individuals often have irregular menstrual periods, making FAM less reliable for tracking ovulation. Irregular periods can make it challenging to accurately predict fertile days. Choice A is incorrect because FAM is not solely for contraception but also for fertility awareness. Choice B is incorrect as FAM can still be used for tracking fertility even if contraception is not needed. Choice D is incorrect because while pregnancy risk decreases during perimenopause, it is not zero, and FAM can still be helpful for those who wish to avoid pregnancy.