2nd Set

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis?

*1. Abdominal tenderness and chills 2.Increased diuresis and appetite 3.Maternal oral temperature of 100.2º F (37.9º C) 4.Fundus 2 fingerbreadths below umbilicus, midline and firm - Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104º F (37.9º C). This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Increased diuresis and appetite, slight elevation in temperature, and firm fundus, midline below the umbilicus represent normal maternal physiological responses in the immediate postpartum period.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.

*1. Giving tepid sponge baths *2.Applying a hypothermia blanket 3.Covering the client with blankets *4.Administering acetaminophen per protocol 5.Placing ice packs over the client's abdomen and in the axilla and groin - Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks?

1. "I need to restrict my carbohydrate intake." 2."I need to drink at least 3 L of fluid per day." 3."I need to maintain a low-fat and low-cholesterol diet." * 4."I need to be sure to consume foods that are low in sodium." - Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.

The nurse should question a prescription for which medication in the client concurrently receiving tramadol?

1. Beta blockers 2.Histamine H2 antagonists 3.Calcium channel blockers *4.Monoamine oxidase inhibitors (MAOIs) - Tramadol can precipitate a hypertensive crisis if combined with an MAOI. The combination is contraindicated. Its use is not contraindicated with beta blockers, histamine H2 antagonists, or calcium channel blockers.

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?

1. Breathe normally. 2.Turn the head to the right. 3.Exhale slowly and evenly. *4.Take a deep breath, hold it, and bear down. - The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change.

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased?

1. Increased urinary output *2.A fetal heart rate of 180 beats/min 3.Three contractions occurring in a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions - A normal fetal heart rate is 110 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

1. Over the second intercostal space at the left sternal border 2.Over the fourth intercostal space at the right sternal border 3. Over the second intercostal space at the right sternal border * 4.Over the fifth intercostal space in the left midclavicular line - The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?

1. Prevents blue (tet) spells *2.Maintains adequate cardiac output 3.Maintains an adequate hormonal level 4.Maintains the position of the great arteries - A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing is inadequate to maintain adequate cardiac output. The remaining options are incorrect. In addition, tet spells occur in tetralogy of Fallot, not in transposition of the great arteries. Prostaglandin E1 does not affect hormone levels, nor does it affect the position of the arteries.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

1. With food 2.At lunchtime *3.On an empty stomach 4.At bedtime with a snack - Oral doses of levothyroxine should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.

1. bulging anterior fontanel 2.A depressed anterior fontanel *3.A soft and flat anterior fontanel 4.A triangular-shaped anterior fontanel *5.A triangular-shaped posterior fontanel 6.Size of posterior fontanel is 4 cm by 6 cm - The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. The posterior fontanel is triangular shaped, may be closed at birth or close at about 2 months of age, and is 1 cm by 2 cm in size. A bulging fontanel may indicate increased intracranial pressure. A depressed fontanel may indicate dehydration.