ATI RN
Nursing Interventions for Pediatric Respiratory Distress Questions
Question 1 of 5
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
Correct Answer: D
Rationale: Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen pelvic floor muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period.
Question 2 of 5
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time?
Correct Answer: D
Rationale: The correct answer is D because the nurse needs to differentiate between postpartum blues and more serious conditions like postpartum depression. By asking if the patient is able to care for her baby, the nurse is assessing the severity of the symptoms and determining if the patient needs further evaluation or support. This response shows a proactive approach to addressing the patient's concerns and ensuring proper care.
Question 3 of 5
Which nursing measure would be most appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?
Correct Answer: B
Rationale: The most appropriate nursing measure to prevent thrombophlebitis in the recovery period following a cesarean birth is option B) Assist the patient in performing leg exercises every 2 hours. Performing leg exercises helps promote circulation and prevents blood stasis, which is crucial in reducing the risk of thrombophlebitis. This intervention aids in maintaining venous return, preventing the formation of blood clots, and promoting overall vascular health. Additionally, leg exercises help prevent muscle atrophy and improve the patient's mobility and comfort during the recovery period. Options A, C, and D are incorrect for preventing thrombophlebitis. Limiting oral intake of fluids for the first 24 hours (Option A) does not directly address the risk of thrombophlebitis and may lead to dehydration, which can actually increase the risk of clot formation. While ambulating the patient (Option C) is important for preventing complications post-cesarean, it may not be as effective in preventing thrombophlebitis as targeted leg exercises. Rolling a bath blanket behind the patient's knees (Option D) may provide comfort but does not address the underlying issue of promoting circulation and preventing clot formation in the same way that leg exercises do. In an educational context, it is crucial for nursing students to understand the rationale behind preventive measures for postoperative complications like thrombophlebitis. By grasping the importance of interventions such as leg exercises, students can provide evidence-based care to promote optimal patient outcomes and prevent potentially serious complications.
Question 4 of 5
Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C (99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated?
Correct Answer: C
Rationale: The correct answer is C because prostaglandin analogs can be administered intramuscularly to stop uterine bleeding in this scenario. Oxytocin may be considered, but it is not administered in a piggyback solution. Methylergonovine is contraindicated in the presence of hypertension, which the patient has. Increasing parenteral fluids will not directly address the uterine bleeding issue.
Question 5 of 5
To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the patient's
Correct Answer: A
Rationale: In the context of pediatric respiratory distress, understanding the use of methylergonovine (Methergine) is crucial for nurses. Methylergonovine is a medication primarily used to manage postpartum hemorrhage by stimulating uterine contractions, thereby improving uterine tone. Therefore, the correct answer is A) uterine tone. Option B) pain level is incorrect because methylergonovine is not used to assess or manage pain. Option C) blood pressure is incorrect as monitoring blood pressure is not the primary purpose of administering methylergonovine. Option D) last voiding is also incorrect as it is unrelated to the desired response of this medication. In an educational context, nurses must be knowledgeable about the actions and expected outcomes of medications they administer. Understanding the specific effects of methylergonovine, such as assessing uterine tone, is essential to ensure safe and effective patient care. By selecting the correct answer, nurses can monitor and evaluate the therapeutic response of the medication accurately, promoting positive patient outcomes in scenarios where methylergonovine is utilized.