Nokea
The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
- A. Reposition the monitor
- B. Turn the client to her left side
- C. Ask the client to ambulate
- D. Prepare the client for delivery
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.
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A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Water will deplete electrolytes resulting in metabolic acidosis.
- B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
- D. Saline will increase peristalsis in the bowel.
Correct Answer: A
Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:
- A. Sleep in a reclining position
- B. Eat large meals
- C. Avoid carbonated beverages
- D. Lie down after eating
Correct Answer: C
Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse-Friderichsen syndrome, which is:
- A. Peripheral circulatory collapse
- B. Syndrome of inappropriate antidiuretic hormone
- C. Cerebral edema resulting in hydrocephalus
- D. Auditory nerve damage resulting in permanent hearing loss
Correct Answer: A
Rationale: Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome.
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.
A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250 mg per mL. How many mL should the nurse administer?
Correct Answer: 0.8
Rationale: Dose: 200 mg ÷ 250 mg/mL = 0.8 mL. The nurse should administer 0.8 mL.