Nokea
When caring for a neonate born at 30 weeks' gestation who is in an isolette and receiving continuous oxygen, which of the following would the nurse use as the best method to determine the effectiveness of this treatment?
- A. Evidence of cyanosis on mouth, hands, and feet.
- B. Continuous pulse rate monitoring.
- C. Arterial blood gas levels.
- D. Percentage of oxygen delivered.
Correct Answer: C
Rationale: Arterial blood gas levels provide the most accurate assessment of oxygenation and ventilation status, indicating the effectiveness of oxygen therapy.
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A nurse is discussing the contraceptive injection with a client. Which of the following benefits should the nurse highlight?
- A. It provides protection against STIs.
- B. It is effective for 3 months per injection.
- C. It requires daily administration.
- D. It guarantees regular periods.
Correct Answer: B
Rationale: The contraceptive injection is effective for 3 months per injection, offering convenient long-term contraception. It does not protect against STIs, is not administered daily, and may cause irregular periods.
A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?
- A. Move to the entrance of the hospital and check each person leaving.
- B. Go to the obstetrics unit to determine if they need help with the situation.
- C. Call the nursery to ask which baby is missing.
- D. Observe individuals in the area for large bags or oversized coats.
Correct Answer: D
Rationale: Observing for suspicious items like large bags helps identify potential abductors during a Code Pink.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
- A. Resting period of 2 minutes between contractions.
- B. Normal patellar and elbow reflexes for the past 2 hours.
- C. Softening of the cervix and beginning effacement.
- D. Leaking of clear amniotic fluid in small amounts.
Correct Answer: C
Rationale: Prostaglandin gel is used for cervical ripening. A therapeutic response is indicated by cervical softening and effacement, preparing the cervix for labor. Resting periods and reflexes are unrelated to the gel's purpose, and leaking amniotic fluid suggests rupture of membranes, not a direct effect of the gel.