Nokea
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
- A. Encourage the mother to ambulate.
- B. Notify the primary health care provider.
- C. Massage the fundus gently until it is firm.
- D. Document fundal position, consistency, and height.
Correct Answer: C
Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.
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The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?
- A. It sounds as if the hepatitis may be worsening.'
- B. It is necessary to isolate the child from others in the home.'
- C. The jaundice may appear to get worse before it begins to resolve.'
- D. You need to bring the child to the health care clinic to see the primary health care provider.'
Correct Answer: C
Rationale: The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child's condition, specifically changes in neurological status, bleeding, and fluid retention. Based on this information, the statements in the remaining options are incorrect.
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
- A. Shock
- B. A head injury
- C. Respiratory insufficiency
- D. Increased intracranial pressure
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?
- A. Bed rest
- B. Intravenous fluids
- C. Supplemental oxygen
- D. Meperidine hydrochloride
Correct Answer: D
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone. These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. The remaining options are appropriate prescriptions for treating vaso-occlusive pain crisis.
A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
- A. Take the client's vital signs.
- B. Perform a Leopold's maneuver.
- C. Perform a manual sterile vaginal exam.
- D. Test the vaginal fluid with a Nitrazine strip.
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.
A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?
- A. Trapeze
- B. Bed cradle
- C. Draw sheet
- D. Alternating pressure mattress
Correct Answer: D
Rationale: The reddened heel results from the pressure of the foot against the mattress. An alternating pressure mattress is effective at minimizing pressure points. The bed cradle will keep the linens off of the client's lower extremities but will not assist with the management of a reddened heel. A draw sheet and trapeze are of general use for this client, but they are not specific for dealing with the reddened heel.