Nokea
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 Seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: 6 contractions in 10 minutes. This indicates hyperstimulation of the uterus, putting the fetus at risk. Discontinuing oxytocin is necessary to prevent uterine tachysystole. Contractions lasting 60 seconds (choice A) are normal. Non-repetitive early decelerations (choice B) are benign. Moderate variability of the fetal heart rate (choice D) is a reassuring sign of fetal well-being.
You may also like to solve these questions
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States < No, the baby is too tired to be held=. Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This response promotes education and empowerment by showing the client the proper way to hold and feed the newborn, fostering a supportive and educational environment. Insisting on the mother picking up the newborn (choice A) disregards the mother's wishes and may lead to conflict. Persuading the client to breastfeed (choice C) may not be appropriate if the client has chosen bottle-feeding. Taking the newborn to the nursery (choice D) does not address the client's desire to feed her baby.
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? - p170-171 - postprocedure bottom of 170 and goes into top of 171.
- A. The plastibell will be removed 4 hours after the procedure
- B. Notify the provider is the end of your penis appears dark red
- C. Make sure the newborn's diaper is snug
- D. Yellow exudate will form at the surgical site in 24 hours
Correct Answer: D
Rationale: The correct answer is D. Yellow exudate forming at the surgical site in 24 hours is expected after plastibell circumcision due to the healing process. This exudate consists of dead cells and is a normal part of wound healing. It is important for the parents to be aware of this so they do not mistake it for an infection or abnormality.
Explanation for other choices:
A: The plastibell is not removed after 4 hours; it falls off on its own in about 5-10 days.
B: Dark red appearance at the end of the penis could indicate a potential issue, but immediate notification of the provider is not necessary.
C: Ensuring the newborn's diaper is snug is unrelated to the circumcision technique.
E, F, G: No information provided.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client which of the following vaccinations? Select all the apply
- A. Varicella
- B. human papillomavirus
- C. Diphtheria - acellular pertussis
- D. inactivated influenza
- E. measles, mumps, and rubella
Correct Answer: C,D
Rationale: The correct answers are C (Diphtheria - acellular pertussis) and D (inactivated influenza) for a client at 30 weeks gestation. These vaccines are safe during pregnancy and provide protection to both the mother and the developing fetus. Diphtheria and pertussis can cause severe complications for newborns, so vaccinating the mother during pregnancy helps pass on immunity. Influenza vaccination is recommended to reduce the risk of severe illness in pregnant women and their babies. Choices A, B, and E are contraindicated during pregnancy due to potential harm to the fetus.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should use an oil based vaginal lubricant when inserting your diaphragm
- B. You should store your diaphragm in sterile water after each use
- C. You should keep the diaphragm in place for at least 4 hours after intercourse
- D. You should have your provider refit you for a new diaphragm
Correct Answer: D
Rationale: The correct answer is D: You should have your provider refit you for a new diaphragm. This is important because postpartum changes, such as weight gain or loss, can affect the fit of the diaphragm. A proper fit is crucial for effective contraception. Storing the diaphragm in sterile water (B) is incorrect as it can damage the device. Using oil-based lubricants (A) is not recommended as they can weaken the diaphragm. Keeping the diaphragm in place for 4 hours after intercourse (C) is unnecessary and may increase the risk of infection.
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
- A. Indirect Coombs test
- B. Liver enzymes
- C. Uric acid level
- D. Serum medication level
Correct Answer: D
Rationale: The correct answer is D: Serum medication level. The nurse should review this value during tocolytic therapy with magnesium sulfate because it is crucial to monitor the therapeutic range of magnesium to prevent toxicity. Monitoring serum levels helps ensure the medication is effective yet safe for the client and the baby.
A: Indirect Coombs test is used to detect antibodies on the surface of red blood cells, not relevant in this scenario.
B: Liver enzymes may be affected by magnesium sulfate but are not directly related to monitoring the medication's therapeutic effect.
C: Uric acid level is not typically monitored during tocolytic therapy with magnesium sulfate.
E, F, G: Irrelevant options.