Nokea
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: The correct action for the nurse to take when encountering a boggy uterus and vaginal bleeding after delivery is to massage the fundus. Massaging the fundus helps the uterus contract, which can reduce vaginal bleeding. Checking vital signs may be important but addressing the uterine atony and bleeding takes precedence. Offering a bedpan or checking for perineal lacerations are not the immediate actions needed to manage postpartum hemorrhage.
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The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.
In this municipality, what should the nursing health care plan focus on?
- A. Rehabilitative services
- B. All of these services
- C. Health promotion and disease prevention
- D. Curative services
Correct Answer: C
Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.
What action is best for the community health nurse to take if the nurse suspects that an infant is being physically abused?
- A. Follow agency protocols to report suspected abuse.
- B. Report suspicions to the local child abuse reporting hotline.
- C. Educate the child's caregivers about growth and development issues.
- D. Call the police department to have the child removed from the home.
Correct Answer: A
Rationale: When a community health nurse suspects that an infant is being physically abused, the best course of action is to follow agency protocols to report the suspected abuse. This is essential to ensure that the appropriate authorities are informed, and proper interventions can be initiated. Reporting suspicions to the local child abuse reporting hotline (Choice B) can be a part of the agency protocols but may not cover all necessary steps. Educating the child's caregivers about growth and development (Choice C) is not appropriate in cases of suspected abuse, as the immediate focus should be on the safety and well-being of the infant. Calling the police department to have the child removed from the home (Choice D) is not the primary role of the nurse; the proper authorities should handle the removal process after an investigation.
The appropriate order of steps in active management of the third stage of labor includes:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
- C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
- D. Controlled cord traction, fundal massage, and oxytocin.
Correct Answer: C
Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.
During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?
- A. Pulse oximetry reading of 89%
- B. Crackles at the base of the lungs on auscultation
- C. Rapid shallow respirations with intermittent wheezes
- D. Excessive thirst with a dry cracked tongue
Correct Answer: C
Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.