1. As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
A. The baby is asleep.
B. There is uteroplacental insufficiency.
C. There is a vagal response.
D. The umbilical cord is compressed.
B. Cervical effacement
C. Infrequent contractions
D. Progressive cervical dilation
Answer D is correct. The expected effect of Pitocin is progressive cervical dilation. Pitocin causes more intense contractions, which can increase the pain; thus, answer A is incorrect. Answers B and C are incorrect because cervical effacement is caused by pressure on the presenting part and there are not infrequent contractions.
3. The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
A. Notify the physician
B. Apply oxygen
C. Do nothing; this is a normal O2 sat for a 9-year-old
D. Assess the child’s pulse
Answer B is correct. Remember the ABC’s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%–100%. Answer A is important but not the priority, answer B is inappropriate, and answer D is also not the priority.
A. The baby is asleep.
B. There is uteroplacental insufficiency.
C. There is a vagal response.
D. The umbilical cord is compressed.
Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental insufficiency, or lack of oxygen. Answer A is incorrect because there is no data to support the conclusion that the baby is asleep; answer B results in a variable deceleration; and answer C is indicative of an early deceleration.
2. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
A. A rapid deliveryB. Cervical effacement
C. Infrequent contractions
D. Progressive cervical dilation
Answer D is correct. The expected effect of Pitocin is progressive cervical dilation. Pitocin causes more intense contractions, which can increase the pain; thus, answer A is incorrect. Answers B and C are incorrect because cervical effacement is caused by pressure on the presenting part and there are not infrequent contractions.
3. The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
A. Notify the physician
B. Apply oxygen
C. Do nothing; this is a normal O2 sat for a 9-year-old
D. Assess the child’s pulse
Answer B is correct. Remember the ABC’s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%–100%. Answer A is important but not the priority, answer B is inappropriate, and answer D is also not the priority.
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