maternal and child
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of: A. Increased nasal congestion. B. Nasal polyps. C. Bleeding tendencies. D. Tinnitus and diplopia.
A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time? A. Timing and recording length of contractions. B. Monitoring. C. Preparing for an emergency cesarean birth. D. Checking the perineum for bulging.
A. The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child? A. Cola with ice B. Yellow noncitrus Jello C. Cool cherry Kool-Aid D. A glass of milk
B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to: A. Isolate the client from other patients. B. Maintain a safe environment. C. Orient the client to time, place, and person. D. Establish a trusting relationship.
B. It is of paramount importance to prevent the client from hurting himself or herself or others.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should: A. Place the client in a private room. B. Wear an N 95 respirator when caring for the client. C. Put on a gown every time when entering the room. D. Don a surgical mask with a face shield when entering the room.
B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.
