Nokea
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in hr.
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: Methylergonovine is a medication used to help contract the uterus and control postpartum hemorrhage. One of its side effects is vasoconstriction, which can lead to increased blood pressure. The client's blood pressure of 142/92 mm Hg is elevated, and administering methylergonovine could further increase the blood pressure, potentially causing harm to the client. It is important to withhold the medication in this situation to prevent worsening of hypertension. The other assessment findings are within normal ranges and do not contraindicate the administration of methylergonovine.
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A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
- A. Palpate the client's uterine fundus.
- B. Assist the client on a bedpan to urinate.
- C. Prepare to administer oxytocic medication.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
Family roles are often defined by culture and religion. What does the nurse know about collectivism?
- A. Collectivist cultures place an emphasis on individuality.
- B. Decisions are made for the benefit of the individual person, then the family.
- C. A person from a collectivist culture might leave treatment decisions to their family.
- D. These cultures believe that it is best for society when everyone decides on their own health care.
Correct Answer: C
Rationale: Collectivist cultures prioritize family and group decision-making over individual choices.
The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
The nurse provides education regarding female sterilization. What important information is provided?
- A. “You will need to wait 3 months before you are sterile.â€
- B. “You can have this procedure in the hospital after you give birth.â€
- C. “Fertilization will affect your milk supply for breast-feeding.â€
- D. “Tubal ligation is reversible.â€
Correct Answer: D
Rationale: The important information provided regarding female sterilization is that tubal ligation, which is a form of female sterilization, is generally considered irreversible. This means that it is a permanent method of contraception and should not be relied upon as a temporary solution. It is important for individuals considering this procedure to understand that it is meant to be permanent and should be approached as such. If there is any consideration for future fertility, alternative contraceptive options should be discussed with a healthcare provider.
A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
- A. Eat dry crackers before getting out of bed.
- B. Avoid eating throughout the day.
- C. Increase intake of spicy foods.
- D. Consume large, infrequent meals.
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.