Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
A. Prepare the equipment necessary to initiate an amnioinfusion.
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
B. Administer oxygen at 10 L/min via a nonrebreather face mask.
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
C. Discontinue the infusion of oxytocin.
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
D. Place the client in a left lateral position.
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. This position can help improve uteroplacental blood flow and potentially resolve the variable decelerations.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Similar Questions
A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply.)
A. Nulliparity.
Nulliparity (never having given birth) is a known risk factor for ovarian cancer. Women who have never had children have a higher risk compared to those who have. This is believed to be associated with the number of ovulatory cycles a woman experiences throughout her lifetime.
B. History of breastfeeding.
History of breastfeeding does not have a direct link to ovarian cancer risk. In fact, breastfeeding is associated with a reduced risk of both breast and ovarian cancer due to hormonal changes that occur during lactation.
C. Previous use of oral contraceptives.
Previous use of oral contraceptives is associated with a decreased risk of ovarian cancer. Women who have used birth control pills have a lower risk compared to those who have never used them. The protective effect is believed to be due to the suppression of ovulation.
D. History of breast cancer.
History of breast cancer is not a risk factor for ovarian cancer. Although both cancers are related to the reproductive system, they have distinct risk factors and characteristics.
E. Hormone replacement therapy.
Hormone replacement therapy (HRT) is a potential risk factor for ovarian cancer, especially long-term use. The hormones used in HRT can affect hormone levels and may increase the risk of ovarian cancer.
Full Explanation
Choice A rationale:
Nulliparity (never having given birth) is a known risk factor for ovarian cancer. Women who have never had children have a higher risk compared to those who have. This is believed to be associated with the number of ovulatory cycles a woman experiences throughout her lifetime.
Choice B rationale:
History of breastfeeding does not have a direct link to ovarian cancer risk. In fact, breastfeeding is associated with a reduced risk of both breast and ovarian cancer due to hormonal changes that occur during lactation.
Choice C rationale:
Previous use of oral contraceptives is associated with a decreased risk of ovarian cancer. Women who have used birth control pills have a lower risk compared to those who have never used them. The protective effect is believed to be due to the suppression of ovulation.
Choice D rationale:
History of breast cancer is not a risk factor for ovarian cancer. Although both cancers are related to the reproductive system, they have distinct risk factors and characteristics.
Choice E rationale:
Hormone replacement therapy (HRT) is a potential risk factor for ovarian cancer, especially long-term use. The hormones used in HRT can affect hormone levels and may increase the risk of ovarian cancer.
A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?
A. Heart disease.
Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.
B. Cervical dilation of 2 cm.
Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.
C. Gestational age of 34 weeks.
A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.
D. Allergy to penicillin.
Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.
Full Explanation
Choice A rationale:
Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.
Choice B rationale:
Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.
Choice C rationale:
A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.
Choice D rationale:
Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
A. "Increase potassium intake.”
Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.
B. "Increase fluid intake to 3 liters per day.”
Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.
C. "Decrease sodium intake before menstruation.”
Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.
D. "Decrease daily fiber intake.”
Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.
Full Explanation
Choice A rationale:
Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.
Choice B rationale:
Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.
Choice C rationale:
Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.
Choice D rationale:
Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.