Nokea
The nurse is monitoring a 20-year-old woman in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if
- A. the contractions occur at 3-minute intervals and last more than 60 seconds.
- B. the contractions occur at 2.5-minute intervals and last more than 60 seconds.
- C. the contractions occur at 2-minute intervals and last more than 90 seconds.
- D. the contractions occur at 2-minute intervals and last more than 60 seconds.
Correct Answer: C
Rationale: contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds) allows for longer resting time between contractions
You may also like to solve these questions
The nurse is caring for a client with Cushing's syndrome. Which of the following nursing actions would be of HIGHEST priority?
- A. Implement measures to prevent skin breakdown.
- B. Plan measures to prevent infections.
- C. Teach the client signs and symptoms of hyperglycemia.
- D. Instigate measures to prevent fluid overload.
Correct Answer: D
Rationale: respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention
The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
- A. Redness or inflammation of the tissue.
- B. Mottling or graying of the tissue.
- C. The client states that she feels a burning and tingling sensation in the area.
- D. The client states that she feels a numbness and a cold sensation in the area.
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.
A patient received meperidine (Demerol) 75 mg IM 2 hours ago for complaints of pain. The patient turns on his call light and tells the nurse he has to go to the bathroom. The physician has ordered BPR (bathroom privileges). The nurse should
- A. obtain a bedside commode for the patient's use and provide privacy.
- B. help the patient to sit on the side of the bed before proceeding to the bathroom.
- C. provide a bedpan for the patient's use and pull the curtains.
- D. get another nurse and together assist the client to the bathroom.
Correct Answer: B
Rationale: side effects of medication include decreased BP, orthostatic hypotension, bradycardia
The nurse is caring for a 33-year-old woman after delivering an 8 lb 4 oz girl with talipes equinovarus. The woman confides to the nurse, 'I feel so bad that my baby is abnormal.' Which of the following responses by the nurse is BEST?
- A. It's understandable that you feel this way, but there are treatments to correct your baby's problem.
- B. Your baby is not really abnormal. Her feet just look different because of the way the muscles pull.
- C. You have nothing to feel guilty about. The abnormality is not your fault.
- D. Don't feel bad. You baby's abnormality can be corrected surgically.
Correct Answer: A
Rationale: accepts feelings and gives correct information, serial casting is used
A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights.
Which of the following is the best plan of care that would meet the needs of this client INITIALLY?
- A. Point out to the client the secondary gain that results from her behavior.
- B. Demonstrate to the client the irrational nature of these fears.
- C. Encourage the client to rely on significant others for support.
- D. Allow the client to avoid the situations that are anxiety provoking.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) secondary gain (attention and assistance received) is not the motivation of a phobic patient, remain nonjudgmental (2) ineffective in relieving behavior, may increase anxiety and feelings of guilt (3) should encourage patient to remain independent (4) correct-phobia is fixed channel for discharge of tension from unconscious conflict