Nokea
Twelve hours after vaginal delivery, Nurse Kayla palpates the fundus of a primiparous patient and finds it to be firm, above the umbilicus and deviated to the right. What is the BEST thing for Nurse Kayla to do for the patient?
- A. Contact the physician for an order of methylergonovine
- B. Gently massage the fundus to expel the clots
- C. Encourage patient to ambulate and to void
- D. Document this is a normal finding in the patient's records
Correct Answer: C
Rationale: The best thing for Nurse Kayla to do for the patient is to encourage her to ambulate and to void. In this scenario, the fundus being firm, above the umbilicus, and deviated to the right indicates uterine atony with a full bladder. This finding is suggestive of a distended bladder pushing the uterus upwards and to the right. Encouraging the patient to ambulate helps promote uterine contractions, which can aid in the firming up of the uterus. Additionally, emptying the bladder will help the uterus to contract and return to its midline position. This intervention is non-invasive and promotes normal postpartum recovery without the need for medication or excessive manipulation.
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A nurse is caring for a patient with limited English proficiency. What action should the nurse take to ensure effective communication with the patient?
- A. Speak loudly and slowly to help the patient understand
- B. Use medical jargon to convey information more efficiently
- C. Obtain interpreter services or language assistance as needed
- D. Ignore the patient's language barriers and focus on nonverbal communication
Correct Answer: C
Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.
A patient with a history of heart failure is prescribed carvedilol. Which parameter should the nurse monitor closely during carvedilol therapy?
- A. Blood glucose levels
- B. Serum potassium levels
- C. Blood pressure
- D. Liver function tests Medical Surgical Nursing
Correct Answer: C
Rationale: Carvedilol is a beta-blocker primarily used to manage heart failure and hypertension. Monitoring blood pressure closely during carvedilol therapy is crucial because it helps assess the drug's effectiveness in managing heart failure and controlling hypertension. Carvedilol works by blocking certain receptors in the heart and blood vessels, which can lower blood pressure. Monitoring blood pressure fluctuations allows healthcare providers to adjust the dosage accordingly to achieve optimal results and prevent potential complications in patients with heart failure. While monitoring blood glucose levels, serum potassium levels, and liver function tests are essential in managing other conditions or medications, the priority in a patient being prescribed carvedilol for heart failure is to monitor blood pressure levels.
Nursing diagnosis commonly used when working with Sandro is
- A. ineffective role performance
- B. Compromised family coping
- C. impaired social interaction
- D. risk for injury.
Correct Answer: C
Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.
A patient is prescribed an angiotensin-converting enzyme (ACE) inhibitor for heart failure. Which laboratory parameter should the nurse monitor closely during ACE inhibitor therapy?
- A. Serum potassium levels
- B. Serum sodium levels
- C. Blood glucose levels
- D. Serum creatinine levels
Correct Answer: A
Rationale: The nurse should monitor serum potassium levels closely during ACE inhibitor therapy because ACE inhibitors can lead to an increase in serum potassium levels, known as hyperkalemia. ACE inhibitors block the conversion of angiotensin I to angiotensin II, which in turn decreases aldosterone secretion. Aldosterone normally acts in the kidneys to reabsorb sodium and water and excrete potassium. Therefore, when aldosterone secretion is decreased due to ACE inhibitor therapy, there can be an increase in potassium retention, potentially leading to hyperkalemia. Monitoring serum potassium levels is essential to prevent complications associated with hyperkalemia, such as cardiac arrhythmias.
A woman in active labor demonstrates persistent fetal malpresentation, with the fetus in a transverse lie position. What nursing intervention should be prioritized to address this abnormal labor presentation?
- A. Administering intravenous magnesium sulfate for uterine relaxation
- B. Preparing for immediate external cephalic version (ECV)
- C. Facilitating immediate cesarean section
- D. Applying external fetal monitoring to assess fetal well-being
Correct Answer: C
Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.