Nokea
The nurse is monitoring a primiparous client with postpartum hemorrhage. Which intervention is the highest priority?
- A. Administer oxygen at 2 L/min.
- B. Insert a second IV line.
- C. Massage the fundus vigorously.
- D. Administer methylergonovine as ordered.
Correct Answer: B
Rationale: Inserting a second IV line ensures access for fluid resuscitation, critical in managing hemorrhage.
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Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
- A. BPD is an acute disease that can be treated with antibiotics.'
- B. My baby may require permanent assisted ventilation.'
- C. Bronchodilators can cure my baby's condition.'
- D. My baby may have seizures later on in life because of this condition.'
Correct Answer: B
Rationale: BPD is a chronic lung condition that may require long-term respiratory support, including permanent assisted ventilation.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
- A. Check the status of the fetal heart rate.
- B. Turn the client to her right side.
- C. Test the leaking fluid with nitrazine paper.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.
Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
- A. The neonate is at risk because of multiple factors.
- B. Oxygen is being administered at a level of $21%.
- C. The neonate was alkalotic immediately after birth.
- D. Phototherapy is likely to be ordered by the pediatrician.
Correct Answer: A
Rationale: Preterm neonates, especially those with low birth weight and receiving oxygen, are at risk for ROP due to immature retinal development.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.