Nokea
The nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. Which finding would prompt the nurse to discontinue the oxytocin infusion?
- A. Fetal heart rate of 140 bpm
- B. Uterine contractions every 2 minutes lasting 60 seconds
- C. Fetal heart rate variability of 6-10 bpm
- D. Late decelerations with each contraction
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency a serious complication of oxytocin-induced hyperstimulation. Discontinuing oxytocin is necessary to restore fetal oxygenation. The other findings are normal or expected during labor induction.
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The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
- A. Temperature of 100.2°F
- B. Blood pressure of 110/70 mmHg
- C. Respiratory rate of 24 breaths per minute
- D. Itching and rash on the trunk
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assess vital signs
- D. Assign her to a room with someone her own age
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
- A. The pain he has is due to the presence of too many red blood cells.
- B. He will be able to go snow skiing with his friends as long as he stays warm.
- C. He will need extra fluids in summer to prevent dehydration.
- D. There is very little chance that his brother will have sickle cell.
Correct Answer: C
Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.
The client is admitted with a diagnosis of placenta accreta. Which complication is most likely to occur?
- A. Maternal hemorrhage
- B. Fetal distress
- C. Preterm labor
- D. All of the above
Correct Answer: D
Rationale: Placenta accreta where the placenta abnormally adheres to the uterine wall increases the risk of maternal hemorrhage (during delivery) fetal distress (from placental dysfunction) and preterm labor (from interventions). All are potential complications.
The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: A
Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (B) is for rectal exams, prone (C) for back surgeries, and Trendelenburg (D) for shock or upper abdominal access.