Nokea
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
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A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?
- A. Altered nutrition: less than body requirements related to nausea and vomiting
- B. Risk for altered family processes related to the client's age
- C. Ineffective individual coping related to denial of pregnancy
- D. Knowledge deficit related to the client's developmental stage and age
Correct Answer: D
Rationale: The correct answer is D: Knowledge deficit related to the client's developmental stage and age. This nursing diagnosis is most important because the client's lack of understanding about how pregnancy occurs indicates a significant gap in knowledge. It is crucial to provide education on sexual health and reproduction to prevent future unplanned pregnancies and promote informed decision-making.
Choice A is incorrect as addressing altered nutrition is important but not the priority in this situation. Choice B is incorrect as the client's age does not necessarily indicate a need for immediate intervention in family processes. Choice C is incorrect as the primary issue is the client's lack of knowledge, not denial of pregnancy.
In summary, choice D is the most important nursing diagnosis as it directly addresses the root cause of the client's situation and has the potential to positively impact her future health and well-being.
A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Reports increased urinary output
- B. Diaphoresis
- C. Reports blurred vision
- D. Shallow respirations
Correct Answer: A
Rationale: The correct answer is A: Reports increased urinary output. In hyperglycemia, the body tries to eliminate excess glucose through urine, leading to increased urinary output. This is known as osmotic diuresis. Diaphoresis (B) is sweating, which is not typically associated with hyperglycemia. Blurred vision (C) is a symptom of prolonged hyperglycemia affecting the eyes but not an immediate finding. Shallow respirations (D) are not directly related to hyperglycemia.