Nokea
The nurse is caring for a woman with a broken arm. Her partner brings in flowers and balloons and is overly affectionate. What phase of the cycle of violence would the nurse suspect?
- A. tension-building
- B. acute battering incident
- C. honeymoon phase
- D. loving phase
Correct Answer: C
Rationale: The honeymoon phase in the cycle of violence is characterized by remorse and attempts by the abuser to regain control through affection or gifts. This phase manipulates the victim into believing the abuse will not recur.
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The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan?
- A. The ductus arteriosus allows blood to bypass the fetal lungs.
- B. One vein carries oxygenated blood from the placenta to the fetus.
- C. The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy.
- D. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta.
Correct Answer: A
Rationale: The ductus arteriosus bypasses fetal lungs. The umbilical vein carries oxygenated blood, and arteries carry deoxygenated blood to the placenta.
What is essential for the nurse to teach a woman who has just had an intrauterine device (IUD) inserted?
- A. Palpate her lower abdomen each month to check the patency of the device.
- B. Remain on bed rest for 24 hours after insertion of the device.
- C. Report any complaints of painful intercourse to the physician.
- D. Insert spermicidal jelly within 4 hours of every sexual encounter.
Correct Answer: C
Rationale: Painful intercourse may indicate IUD displacement or complications.
A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am
- A. Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain
- B. Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr.
- C. Mom may breastfeed ad lib
- D. Draw blood cultures x 3 in A.M.
Correct Answer: B
Rationale: Ampicillin dosage exceeds recommended levels for neonates.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.
What intervention is highest priority for a woman entering the emergency department after a stranger rape?
- A. Create a safe environment.
- B. Offer postcoital contraceptive therapy.
- C. Provide sexually transmitted disease prophylaxis.
- D. Take a thorough health history.
Correct Answer: A
Rationale: Ensuring safety is paramount immediately after trauma.