Nokea
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. This action is appropriate because late decelerations in fetal heart rate (FHR) can indicate uteroplacental insufficiency, leading to fetal hypoxia. Administering oxygen helps increase the oxygen supply to the fetus, potentially improving fetal oxygenation and reducing the risk of hypoxia-related complications.
Choice A is incorrect because bearing down and pushing with contractions can further compromise fetal oxygenation in the presence of late decelerations. Choice C is incorrect as a supine position can worsen uteroplacental perfusion. Choice D, initiating an amnioinfusion, is not indicated for addressing late decelerations in FHR.
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A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. This is the best action to take because sore nipples in breastfeeding mothers are often caused by an improper latch. By assessing the newborn's latch, the nurse can identify any issues such as shallow latch or improper positioning that may be causing the soreness. Correcting the latch can help alleviate the discomfort and promote effective breastfeeding.
Other choices are incorrect:
A: Instructing the client to wait 4 hours between daytime feedings is not appropriate as frequent feeding is important for establishing milk supply and ensuring adequate nutrition for the newborn.
C: Having the client limit the length of breastfeeding to 5 minutes per breast may not address the root cause of sore nipples and could potentially lead to inadequate milk transfer.
D: Offering supplemental formula between feedings is not necessary and may interfere with establishing breastfeeding.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [, (0, 0, 0), (1, 0, 0), (0, 0, 1)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for quick and efficient fluid administration in emergencies or critical conditions.
C: Weighing perineal pads helps monitor postpartum hemorrhage accurately by assessing the amount of blood loss.
Assessing cervical dilation (B) is not indicated unless specified for a specific medical condition. Administering methotrexate (D) is contraindicated in pregnancy and certain medical conditions.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best way to evaluate medication adherence for digoxin. Digoxin has a narrow therapeutic range, so monitoring the serum level ensures the client is taking the correct dose. Choices A, B, and C do not directly assess medication adherence for digoxin. Asking the client may not reflect the actual medication intake, kidney function assessment is important but not for adherence evaluation, and apical pulse rate may be affected by various factors. Checking the serum level provides objective data on the drug concentration in the body, indicating adherence.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: Rationale: The correct answer is D. In the occipitoposterior position, the fetus's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can assess if the hands-and-knees position has helped relieve the pressure on the mother's sacrum, indicating effectiveness.
Incorrect Choices:
A: Suprapubic pain is not directly related to the occipitoposterior position or the hands-and-knees position.
B: Pelvic pressure may not necessarily be alleviated by changing positions in occipitoposterior position.
C: Contractions feeling further apart may not directly correlate with the effectiveness of the hands-and-knees position for back labor relief.