Nokea
What assessment finding would indicate a fluid volume deficit?
- A. skin tenting with testing of skin turgor
- B. hypertension
- C. bradycardia
- D. bounding pulse
Correct Answer: A
Rationale: Skin tenting is a classic sign of dehydration and fluid volume deficit due to reduced skin turgor.
You may also like to solve these questions
The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected?
- A. If your nipples are cracked, you will need to stop breastfeeding.
- B. Pump your milk and throw it away until the infection is gone.
- C. The baby gave you an infection and needs to be on antibiotics.
- D. Continuing to breastfeed will help clear up the condition.
Correct Answer: D
Rationale: Mastitis is generally self-limiting, and continued breastfeeding can help clear up the infection and condition. If antibiotic therapy is indicated, the infection generally resolves within 24 to 48 hours of antibiotic therapy.
A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient’s medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply.
- A. Neonatal macrosomia
- B. Use of a vacuum extractor
- C. Poor oral fluid intake
- D. Urinary catheter during labor
Correct Answer: C
Rationale: Neonatal macrosomia, which can cause edema around the urethra, is a risk factor for UTI. Operative vaginal deliveries, forceps, or vacuum extractor, which can cause edema around the urethra, is a risk factor for UTI. Poor oral fluid intake and urinary catheter insertion during the labor process are also risk factors.
A new father tells a nurse friend that his wife is agitated and acting in a bizarre fashion. She says that she hears voices. Her baby is 2 weeks old. The father is concerned about the care the mother is giving the baby. The nurse should:
- A. Tell the father that this is severe postpartum blues and will pass in a few days if he shows enough support.
- B. Suggest that the father try talking to his wife to find out what is bothering her about being a new mother.
- C. Explain that the mother will probably need psychotherapy and refer him to support groups.
- D. Tell the father to call the physician immediately and not to leave the woman alone with the baby.
Correct Answer: D
Rationale: The symptoms described may indicate postpartum psychosis a serious condition that requires immediate medical intervention to ensure the safety of both the mother and the baby.
A postoperative cesarean section woman is to receive morphine 4 mg q 3 -4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth.
- A. 0.4 mL
- B. 0.6 mL
- C. 0.8 mL
- D. 1.0 mL
Correct Answer: B
Rationale: The nurse needs to administer 4 mg, and the syringe has 10 mg per 1 mL. Therefore, 4 mg will require 0.4 mL, and 0.6 mL will be wasted.
When referring to the 4 T’s of PPH, what does tissue refer to?
- A. Placental tissue or membranes are retained.
- B. Tissue of the perineum is torn.
- C. Tissue of the uterus is torn.
- D. Tissue is not perfused.
Correct Answer: A
Rationale: The correct answer is A because in the context of Postpartum Hemorrhage (PPH), the 4 T’s stand for Tone, Trauma, Tissue, and Thrombin. Tissue refers to placental tissue or membranes being retained, leading to excessive bleeding. This can be a common cause of PPH.
Option B is incorrect because it refers to perineal tears, which are related to trauma and not specifically related to tissue retention causing PPH. Option C is incorrect as it refers to uterine tissue tears, which is more related to trauma rather than retained tissue. Option D is incorrect because it refers to tissue not being perfused, which is not directly related to the concept of tissue retention causing PPH.