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Questions 158

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Question 1 of 5

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:

Correct Answer: B

Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.

Question 2 of 5

A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:

Correct Answer: D

Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.

Question 3 of 5

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:

Correct Answer: B

Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.

Question 4 of 5

A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

Correct Answer: D

Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.

Question 5 of 5

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

Correct Answer: D

Rationale: Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.

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