Nokea
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
- A. Edema, basilar rales, and an irregular pulse.
- B. Increased urinary output, and tachycardia.
- C. Dyspnea, bradycardia, and hypertension.
- D. Regular heart rate, and hypertension.
Correct Answer: A
Rationale: Edema, basilar rales, and an irregular pulse indicate potential cardiac decompensation, which is of greatest concern in a woman with heart disease during labor.
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A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
- A. Transition labor with contractions every 2 minutes, lasting 90 seconds each
- B. Early labor with contractions every 5 minutes, lasting 40 seconds each
- C. Active labor with contractions every 31 minutes, lasting 60 seconds each
- D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Correct Answer: A
Rationale: Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued.
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
- A. Administer oxygen
- B. Feed the infant glucose water (10%)
- C. Obtain a blood glucose level
- D. Decrease environment stimuli
Correct Answer: C
Rationale: Jitteriness in LGA infants suggests hypoglycemia, so obtaining a blood glucose level (C) is the priority.
A pregnant patient asks the nurse if she can double her prenatal vitamin dose because she does not like to eat vegetables. What is the nurse's response regarding the danger of taking excessive vitamins?
- A. Increases caloric intake
- B. Has toxic effects on the fetus
- C. Increases absorption of all vitamins
- D. Promotes development of pregnancy-induced hypertension (PIH)
Correct Answer: B
Rationale: The correct answer is B: Has toxic effects on the fetus. Doubling prenatal vitamin dose can lead to excessive intake of certain vitamins like Vitamin A, which can be harmful to the fetus. Excessive vitamins can cause toxicity and harm the developing baby. Other choices are incorrect: A is irrelevant, C is misleading, and D is not related to excessive vitamin intake.
Which patient is most at risk for a low-birth-weight infant?
- A. 22-year-old, 60 inches tall, normal prepregnant weight
- B. 18-year-old, 64 inches tall, body mass index is <18.5
- C. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
- D. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb
Correct Answer: B
Rationale: The correct answer is B because a low body mass index (<18.5) indicates underweight, which is a risk factor for delivering a low-birth-weight infant. Underweight individuals may have inadequate nutrition and lower reserves for a healthy pregnancy.
Choice A is less likely as the patient has a normal prepregnant weight. Choice C's prepregnant weight being above the norm suggests a healthy weight. Choice D's total weight gain in previous pregnancies being 33 lb indicates a healthy weight maintenance during pregnancy.