Nokea
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement every thirty minutes
Correct Answer: B
Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.
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Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:
- A. Maintaining a high-humidified environment
- B. Furry, soft stuffed animals for play
- C. Showering 3-4 times a day
- D. Wrapping hands in soft cotton gloves
Correct Answer: D
Rationale: Maintaining a low-humidified environment. Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. Wrapping hands in soft cotton gloves to prevent skin damage during scratching.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
- A. A large gush of clear fluid from the vagina
- B. Systolic hypertension
- C. Abdominal rigidity
- D. Increased fetal movements
Correct Answer: C
Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.
The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
- A. Chocolate
- B. Fresh vegetables
- C. Lean meats
- D. Whole grains
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.
A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.