Nokea
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
- A. Mother is concerned about her recovery.
- B. Mother calls infant by name.
- C. Mother lightly touches infant.
- D. Mother is concerned about her weight gain.
Correct Answer: B
Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.
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A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
- A. Administering anticoagulants
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Airway obstruction
- B. Communication impairment
- C. Pain management
- D. Infection risk
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
- A. Notify physician of nonreassuring FHR pattern.
- B. Turn the client to her left side.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Evaluate to see if the monitor strip is reassuring.
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.