Nokea
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
- A. I can administer oxytocin 4 hours after the insertion of the medication
- B. You will need a full bladder prior to the insertion of the medication
- C. Remain in a side-lying position for 15 minutes after the medication is inserted
- D. An antacid will be given 20 minutes prior to the insertion of the medication
Correct Answer: C
Rationale: The correct answer is C: Remain in a side-lying position for 15 minutes after the medication is inserted. This instruction is important because misoprostol can cause uterine contractions leading to potential discomfort or cramping. By remaining in a side-lying position, the client can help the medication remain in the desired location near the cervix, enhancing its effectiveness. This position also helps reduce the risk of the medication leaking out prematurely and ensures optimal absorption.
Choice A is incorrect because oxytocin is not typically administered shortly after misoprostol due to the potential for excessive uterine stimulation. Choice B is incorrect as a full bladder is not necessary for the insertion of misoprostol. Choice D is incorrect as an antacid is not typically required prior to the insertion of misoprostol.
You may also like to solve these questions
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
What is the main cause of mastitis in the postpartum client?
- A. Poor breastfeeding technique
- B. Inadequate hand washing
- C. Systemic maternal infection
- D. Prolonged nursing
Correct Answer: A
Rationale: The correct answer is A: Poor breastfeeding technique. Mastitis in postpartum clients is commonly caused by milk stasis due to inadequate milk removal, which can result from poor breastfeeding technique such as improper latch or infrequent feedings. This leads to inflammation and infection. Inadequate hand washing (B) is important for preventing infection but not the main cause of mastitis. Systemic maternal infection (C) may contribute but is not the primary cause. Prolonged nursing (D) can actually help prevent mastitis by promoting milk flow.
A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she:
- A. drinks two glasses of wine before dinner every night.
- B. has intermittent contractions that are relieved by walking.
- C. had intercourse with her partner last night.
- D. used crack an hour before the symptoms began.
Correct Answer: D
Rationale: The correct answer is D: used crack an hour before the symptoms began. Abruptio placenta is a condition where the placenta prematurely separates from the uterine wall. Substance abuse, such as crack cocaine, can lead to vasoconstriction and increased risk of abruptio placenta due to compromised blood flow to the placenta. This can result in fetal distress and maternal bleeding. The other choices (A, B, C) do not directly correlate with abruptio placenta. Intermittent contractions relieved by walking are more suggestive of Braxton Hicks contractions, intercourse is not a known risk factor for abruptio placenta, and drinking wine does not typically cause this condition.
A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is:
- A. walking around the unit and talking with her partner.
- B. irritable and needs frequent repetition of directions.
- C. expelling feces and the fetal head is crowning.
- D. reading a magazine and talking on the phone.
Correct Answer: B
Rationale: The correct answer is B. In the transition stage of labor, the cervix dilates from 8 to 10 cm. This stage is characterized by intense contractions, increased irritability, and the need for frequent repetition of directions due to the intensity of labor pain. The client being irritable and needing frequent repetition of directions indicates that she is likely in the transition stage of labor.
A: Walking around and talking with her partner is more indicative of the early stage of labor.
C: Expelling feces and the fetal head crowning are more indicative of the second stage of labor.
D: Reading a magazine and talking on the phone are not typical behaviors during the transition stage of labor.
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. This is a common sign of pain in newborns as they may not be able to communicate verbally. It indicates distress and discomfort. Decreased heart rate (A) and pinpoint pupils (C) are not indicative of pain but rather can be signs of other medical conditions. Slowed respirations (D) can be a sign of distress but not specifically pain. Therefore, B is the most relevant and specific indicator of pain in this scenario.