Nokea
The nurse is caring for a client in labor. The fetal heart rate is 80 bpm with moderate variability. The most appropriate initial action by the nurse is to:
- A. Notify the physician
- B. Administer oxygen at 8-10 liters per minute
- C. Reposition the client to her left side
- D. Increase the IV fluid rate
Correct Answer: C
Rationale: A fetal heart rate of 80 bpm indicates bradycardia possibly due to cord compression or uteroplacental insufficiency. Repositioning the client to her left side improves placental perfusion and is the first action. Oxygen notifying the physician or increasing fluids are secondary.
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What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Correct Answer: B
Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.
The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?
- A. Polyuria
- B. Fetal macrosomia
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.'
- B. Increase the fiber in your diet.'
- C. Report nausea to the doctor immediately.'
- D. Drink at least eight large glasses of water a day.'
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so adequate hydration (e.g., 8 glasses of water daily) is essential to flush the bladder and reduce this risk. Walking, fiber, and nausea reporting are not primary concerns with this drug.
A patient is diagnosed with secondary syphilis. The nurse can expect the patient to have:
- A. Copper penny' rash on the palms of the hands and soles of the feet
- B. Localized tumors in the skin, bones, and liver
- C. Chancres and lymphadenopathy
- D. General paresis
Correct Answer: A
Rationale: Secondary syphilis presents with a maculopapular rash, often on the palms and soles, described as ‘copper penny’ lesions. Chancres occur in primary syphilis, tumors (gummas) in tertiary syphilis, and general paresis is a late neurosyphilis complication.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. A temperature elevation
- D. Dry mucous membranes
Correct Answer: B
Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (B) indicate pulmonary edema, correlating with high PAWP. BP drop (A), fever (C), and dry membranes (D) are unrelated.