Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Before administering methylergonovine (Methergine), what priority assessment finding would lead the nurse to hold the medication?
A. Pulse is 90 beats per minute
Pulse is 90 beats per minute is incorrect because a normal heart rate does not contraindicate methylergonovine. The medication’s primary cardiovascular effect is on vascular smooth muscle, not directly on heart rate.
B. Pulse is 110 beats per minutes
Pulse is 110 beats per minute is incorrect because mild tachycardia alone is not a contraindication. However, the nurse should monitor heart rate during administration, especially if hypotension or other complications arise.
C. Blood pressure of 120/70
Blood pressure of 120/70 is incorrect because this is a normal blood pressure and indicates it is safe to give the medication.
D. Blood pressure of 150/90
Blood pressure of 150/90 is correct because hypertension is a contraindication for methylergonovine. Administering the drug to a hypertensive patient can precipitate severe hypertension, stroke, myocardial infarction, or other cardiovascular complications. The nurse must hold the medication, notify the healthcare provider, and implement alternative measures for postpartum bleeding management.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. Pulse is 90 beats per minute is incorrect because a normal heart rate does not contraindicate methylergonovine. The medication’s primary cardiovascular effect is on vascular smooth muscle, not directly on heart rate.
B. Pulse is 110 beats per minute is incorrect because mild tachycardia alone is not a contraindication. However, the nurse should monitor heart rate during administration, especially if hypotension or other complications arise.
C. Blood pressure of 120/70 is incorrect because this is a normal blood pressure and indicates it is safe to give the medication.
D. Blood pressure of 150/90 is correct because hypertension is a contraindication for methylergonovine. Administering the drug to a hypertensive patient can precipitate severe hypertension, stroke, myocardial infarction, or other cardiovascular complications. The nurse must hold the medication, notify the healthcare provider, and implement alternative measures for postpartum bleeding management.
Similar Questions
A 2-year-old child presents to the emergency department with a barking cough, stridor, and a hoarse voice that worsens at night. The child is afebrile but appears anxious and has labored breathing. The nurse suspects croup as the diagnosis. Which of the following interventions should the nurse prioritize to manage the child's symptoms and prevent further respiratory distress?
A. Administer a dose of oral antibiotics to treat the infection
Administer a dose of oral antibiotics to treat the infection is incorrect because most cases of croup are viral in origin (commonly parainfluenza virus). Antibiotics are not indicated unless there is a secondary bacterial infection.
B. Place the child in a supine position to facilitate airflow to the lungs
Place the child in a supine position to facilitate airflow to the lungs is incorrect because lying flat may worsen respiratory distress in a child with croup. Upright positioning is preferred to ease breathing.
C. Encourage the child to lie down to conserve energy
Encourage the child to lie down to conserve energy is incorrect because supine positioning can increase airway obstruction and worsen stridor. Allowing the child to remain upright and calm is safer.
D. Provide a cool mist humidifier or take the child outside into cool night air
Provide a cool mist humidifier or take the child outside into cool night air is correct because cool, moist air helps reduce laryngeal inflammation and edema, which can relieve stridor and improve breathing. This is a first-line, noninvasive intervention to manage mild to moderate croup symptoms while minimizing respiratory distress.
Full Explanation
A. Administer a dose of oral antibiotics to treat the infection is incorrect because most cases of croup are viral in origin (commonly parainfluenza virus). Antibiotics are not indicated unless there is a secondary bacterial infection.
B. Place the child in a supine position to facilitate airflow to the lungs is incorrect because lying flat may worsen respiratory distress in a child with croup. Upright positioning is preferred to ease breathing.
C. Encourage the child to lie down to conserve energy is incorrect because supine positioning can increase airway obstruction and worsen stridor. Allowing the child to remain upright and calm is safer.
D. Provide a cool mist humidifier or take the child outside into cool night air is correct because cool, moist air helps reduce laryngeal inflammation and edema, which can relieve stridor and improve breathing. This is a first-line, noninvasive intervention to manage mild to moderate croup symptoms while minimizing respiratory distress.
A nurse is assessing the growth and development of a 16-year-old adolescent. Which of the following behaviors or physical changes would the nurse expect to observe in a typical adolescent at this stage? (Select all that apply)
A. Full adult height and the cessation of body changes
Full adult height and the cessation of body changes is incorrect because while many adolescents are nearing adult height by age 16, some continue to grow, particularly males. Body changes may still be ongoing, so complete cessation of growth is not typical.
B. A decrease in growth rate and an increase in body fat distribution
A decrease in growth rate and an increase in body fat distribution is correct because by mid-adolescence, the rapid growth of puberty slows, and changes in body composition occur. Females typically experience an increase in body fat, while males may see a decrease in fat with increased muscle mass.
C. Heightened interest in forming intimate relationships outside the family
Heightened interest in forming intimate relationships outside the family is correct because adolescents at this stage begin exploring romantic and sexual relationships and may form emotional attachments with peers or romantic partners.
D. Increased independence and desire for privacy, with a focus on peer relationships
Increased independence and desire for privacy, with a focus on peer relationships is correct because autonomy and identity formation are key developmental tasks of adolescence. Adolescents seek privacy, rely more on peers, and may challenge parental authority as part of normal psychosocial development.
E. Development of secondary sexual characteristics such as facial hair in males and breast development in females
Development of secondary sexual characteristics such as facial hair in males and breast development in females is correct because most adolescents have completed or are in the later stages of puberty by age 16, with secondary sexual characteristics well established.
Full Explanation
A. Full adult height and the cessation of body changes is incorrect because while many adolescents are nearing adult height by age 16, some continue to grow, particularly males. Body changes may still be ongoing, so complete cessation of growth is not typical.
B. A decrease in growth rate and an increase in body fat distribution is correct because by mid-adolescence, the rapid growth of puberty slows, and changes in body composition occur. Females typically experience an increase in body fat, while males may see a decrease in fat with increased muscle mass.
C. Heightened interest in forming intimate relationships outside the family is correct because adolescents at this stage begin exploring romantic and sexual relationships and may form emotional attachments with peers or romantic partners.
D. Increased independence and desire for privacy, with a focus on peer relationships is correct because autonomy and identity formation are key developmental tasks of adolescence. Adolescents seek privacy, rely more on peers, and may challenge parental authority as part of normal psychosocial development.
E. Development of secondary sexual characteristics such as facial hair in males and breast development in females is correct because most adolescents have completed or are in the later stages of puberty by age 16, with secondary sexual characteristics well established.
A 6-month-old infant is diagnosed with a congenital heart defect that causes a left-to-right shunt, resulting in increased pulmonary blood flow. Which of the following defects is most likely?
A. Coarctation of the Aorta
Coarctation of the Aorta is incorrect because this defect causes obstruction of blood flow from the left ventricle to the aorta. It is a pressure load problem (left ventricular hypertension) rather than a left-to-right shunt, and it does not primarily increase pulmonary blood flow.
B. Tetralogy of Fallot
Tetralogy of Fallot is incorrect because this is a cyanotic defect characterized by right-to-left shunting due to pulmonary stenosis and a VSD. Pulmonary blood flow is often decreased rather than increased.
C. Transposition of the Great Arteries
Transposition of the Great Arteries is incorrect because this is a cyanotic defect in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, resulting in parallel circulation. Pulmonary blood flow is not increased by a left-to-right shunt.
D. Ventricular Septal Defect (VSD)
Ventricular Septal Defect (VSD) is correct because it is a acyanotic defect that allows blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure). This left-to-right shunt increases pulmonary blood flow, which can lead to symptoms such as tachypnea, poor weight gain, and frequent respiratory infections. VSDs are the most common congenital heart defect in infants.
Full Explanation
A. Coarctation of the Aorta is incorrect because this defect causes obstruction of blood flow from the left ventricle to the aorta. It is a pressure load problem (left ventricular hypertension) rather than a left-to-right shunt, and it does not primarily increase pulmonary blood flow.
B. Tetralogy of Fallot is incorrect because this is a cyanotic defect characterized by right-to-left shunting due to pulmonary stenosis and a VSD. Pulmonary blood flow is often decreased rather than increased.
C. Transposition of the Great Arteries is incorrect because this is a cyanotic defect in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, resulting in parallel circulation. Pulmonary blood flow is not increased by a left-to-right shunt.
D. Ventricular Septal Defect (VSD) is correct because it is a acyanotic defect that allows blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure). This left-to-right shunt increases pulmonary blood flow, which can lead to symptoms such as tachypnea, poor weight gain, and frequent respiratory infections. VSDs are the most common congenital heart defect in infants.