Nokea
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1]
The correct answers are A and C (Weigh perineal pads).
- A large bore IV catheter may be necessary for rapid fluid resuscitation in emergencies, indicated for critically ill patients.
- Weighing perineal pads is essential to monitor postpartum bleeding, ensuring accurate assessment and timely intervention.
- Assessing cervical dilation (B) is not typically a nursing action but a medical provider's task during labor.
- Administering methotrexate (D) is a medical intervention for conditions like ectopic pregnancy, not within a nurse's scope.
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A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg
- B. Heart rate 98/min
- C. Urine output of 280 mL within 8 hr
- D. Urine negative for ketones
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: Rationale: Choice B is correct because bed rest helps prevent further clot formation and reduces the risk of embolism. Movement can dislodge the clot. Aspirin (Choice A) can increase bleeding risk. Massaging (Choice C) can dislodge clots. Cold compresses (Choice D) can also increase bleeding risk and dislodge clots.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: The correct answer is D: To facilitate bonding between the newborn and parent. Applying the ointment immediately after birth may interfere with the crucial bonding process between the newborn and the parent. It is important for the parent to have uninterrupted skin-to-skin contact and establish a strong emotional connection with the newborn during the first moments after birth. This bonding time is essential for the newborn's emotional well-being and can have long-lasting positive effects on their development. Delaying the instillation of the ointment allows for this important bonding process to occur naturally.
Choice A is incorrect because early identification of infection is crucial and should not be delayed. Choice B is unrelated to the instillation of ointment. Choice C is also unrelated, as the mode of delivery does not affect the timing of ointment instillation.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice A) are not typically associated with nuchal cords. Periauricular papillomas (choice C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice D) is a common newborn rash that is not specifically linked to nuchal cords.