Maternal & Newborn Health Pharmacology Flashcards
Your client is receiving a nonsteroidal anti-inflammatory medication (NSAID) in addition to a narcotic analgesic. The client asks why they aregiving an NSAID because the narcotic analgesic is much better than the NSAID. How would you respond to this client’s question?
A. I don’t know why I suggest that you ask your doctor this question when you see her the next time.
B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain.
C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective.
D. You are getting the NSAID because this NSAID is a placebo, and it is proven to be effective for severe pain.
Correct Answer is C.When your client asks you why they are receiving a nonsteroidal anti-inflammatory medication (NSAID) in addition to a narcotic analgesic because the narcotic analgesic is much better than the NSAID, you would respond by saying, “.You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective”. An NSAID is an adjuvant medication used in combination with narcotic analgesics to treat moderate to severe pain.
Choice A is incorrect. This response is not appropriate because the nurse should know or be able to look up why the NSAID is being given, and they should be able to address this client’s question without referring the client to their doctor. The NSAID is being provided for another reason.
Choice B and D are incorrect. Narcotic analgesic with or without an NSAID is an appropriate intervention for moderate to severe pain. NSAID is added to combat pain more effectively. It is not a placebo.
You are evaluating a Nursing Care Plan for a 6-month-old infant with severe postoperative pain. Which of the following is the best-expected client outcome when the client’s pain is managed effectively?
A. The nurse will assess pre and post analgesic client responses.
B. The infant will not demonstrate any behavioral indications of pain.
C. The nurse will evaluate pre and post analgesic client responses.
D. The infant will not demonstrate any physiological indications of pain.
Explanation
Correct Answer is B. Of all the choices in the question above, the best-expected client outcome when the client’s pain is managed effectively is that “The infant will not demonstrate any behavioral indications of pain.” This expected outcome is client-oriented, specific, and measurable.
Because behavioral indicators of pain are more accurate and reliable than physiological indicators of pain, “The infant will not demonstrate any physiological indications of pain” (Choice D) is not the best client outcome to be listed in the care plan.
Firstly, it is important to understand a Nursing Care Plan and its components to answer this question appropriately. A Nursing Care plan provides direction on the type of nursing care the client may need. Six components of a Student Nursing care plan include Assessment, Diagnosis, Outcomes/Planning, Interventions, Rationale, and Evaluation.
Assessment includes both subjective and objective assessment of the client. Diagnostic component of care plan determines the most likely reason for the client’s problems based on the history, assessment, and lab tests.
Outcomes/Planning column of the care plan is client-oriented – a list of measurable goals for the client is set for example, managing pain with enough medication.
Interventions refer to a set of actions that a nurse can undertake to achieve the outcomes.Interventions are nurse-oriented and are aimed at addressing the diagnoses to achieve the desired outcomes. While addressing the diagnoses and planning a specific intervention, prioritizing is crucial. Life-threatening problems should be given high priority and diagnoses are grouped as having a high, medium, or low priority. Maslow’s hierarchy of needs is often used when setting priorities.
The rationalecolumn is to provide scientific explanation to support the reasons why certain nursing interventions were chosen in the care plan.
Finally, Evaluation refers to evaluating the client’s progress towards achieving the desired outcomes. If the evaluation indicates the client’s progress is not as expected, the Nursing Care plan should be adjusted or rewritten to define a better strategy to achieve desired outcomes.
In this question, the nursing care plan is focused on addressing the infant’s pain. The desired client outcome here is that the “infant will not demonstrate behavioral indicators of pain”. Nursing interventions (Choices A and D) are delivered to evaluate if such an outcome is achieved.
Several parameters can be used in clients’ pain assessment, includes behavioral indicators, physiological indicators, and self-report measures.
Physiological indicators of pain (Choice D) refer to variations in heart rate, blood pressure, oxygen saturation, and breathing patterns. Pain leads to an increase in heart rate and blood pressure, a decrease in oxygen saturation, and more rapid or shallow breathing. However, a big limitation of physiological indicators is that these variations may be due to the underlying illness itself rather than the pain. This makes them less specific for pain. Therefore, this should not be considered the best-expected client outcome to effective pain management
While Self-report measures (verbal/ non-verbal) are considered as the ‘gold standard’ in the pain measurement, these cannot be used in infants because to generate such verbal/non-verbal response, the client should have proper cognitive and language development. Therefore, behavioral measures are used as a proxy for objective pain measurement in infants. These include crying, facial expressions, and body postures, or a combination of these indicators. Facial expressions are the most used behavioral measure in children.
The Neonatal Infant Pain Scale (NIPS)shown below incorporates these behaviors to assess infant pain or distress.
Choices A and C are incorrect. “The nurse will assess pre and post analgesic client responses” (Choice A) and “The nurse will evaluate pre and post analgesic client responses” (Choice C) are appropriate nursing interventions, but they are NOT expected client outcomes. These statements are nurse oriented and not client-oriented.
Choice D is incorrect. “The infant will not demonstrate any physiological indications of pain” is not a very reliable indicationof pain outcomeso this is not thebest-expectedclient outcome when the client’s pain is managed effectively.
Your client is experiencing severe, acute anxiety prior to a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician?
A. Oxycodone
B. Midazolam
C. Clonazepam
D. Haloperidol
Explanation
The correct answer is B. Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of “Rapid Onset” (2 to 5 minutes after IV administration) and “Short Duration” of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, Midazolam would be the most useful for the patient experiencing an acute anxiety attack before or during endoscopic procedures, or before surgery. Additional benefits of Midazolam during procedures are sedation and amnesia. Midazolam as continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep Flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines.
Choice A is incorrect. Oxycodone is an opioid pain medication. This is prescribed for severe pain. It is not indicated for the patient experiencing an acute anxiety attack.
Choice C is incorrect. Clonazepam is a long-acting benzodiazepine often used in anxiety attacks after a traumatic event, panic disorders, or generalized anxiety disorder. Your client has pre-procedural anxiety and, therefore, does not need a long-acting anxiolytic. Your client needs an anxiolytic with a rapid onset of action and short duration. Midazolam fits that criteria among the above list.
Choice D is incorrect. Haloperidol is an antipsychotic and is often used in mental health settings to address acute and severe agitation/ aggression associated with psychiatric disorders (Schizophrenia, Substance intoxication). It would not be useful for a patient experiencing pre-procedural acute anxiety.
The nurse is providing a client with discharge instructions on his newly initiated Digoxin. Which of the following statements by the client indicates he correctly understood the instructions? Select all that apply.
A. “If I note color vision changes, I will call my eye doctor right away.”
B. “I will check my pulse before each dose and if pulse less than 60 bpm, will hold Digoxin and call my doctor.”
C. “I will increase my calcium intake significantly.”
D. “I will make sure I get enough potassium in my daily diet.”
E. “The water pills that I am on may increase the risk of side effects with Digoxin.”
F. “I should avoid medications that have licorice extract.”
Explanation
Correct answers are B, D, E, and F.
A nurse should understand the mechanism of action of Digoxin to understand its uses, side effects, monitoring responsibilities, and patient education elements. Digoxin is a cardiac-glycoside that acts via the Sodium-Potassium pump in the myocardium. It has inotropic (influences contractility), chronotropic (influences heart rate), and dromotropic (influences conduction speed) effects.
Digoxin is a positive inotrope (increases the power of heart contraction) and a negative chronotrope (decreases heart rate by its effect on Sinus Node) and negative dromotrope (reduces the speed of conduction by acting at atrioventricular node level).
Because of these cardiac effects of Digoxin, it is often used in patients with congestive heart failure and arrhythmias like atrial fibrillation.
However, Digoxin has a narrow therapeutic index, which means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Therapeutic serum digoxin levels range from 0.5 to 2 ng/mL. A level higher than two ng/mL is considered toxic.
The nurse needs to understand Digoxin’s side effects and offer proper education to the clients. Some early side effects of Digoxin include visual aberrations (yellowish-green color changes or halos) and gastrointestinal side effects like Nausea, Vomiting, and Lack of Appetite. The first cardiac side effects include Bradycardia (reduced heart rate), but cardiac arrhythmias can follow later.
It is essential to monitor for these early side effects, so the next dose of Digoxin can be held, and the physician can be notified. For inpatients, the nurse should always check the apical heart rate for one full minute before giving Digoxin, and if the heart rate < 60 (adults), the nurse should hold the medication and notify the physician. The heart rate threshold for holding Digoxin in a child is less than 70 beats per minute, and in an infant, it is less than 90-110 beats per minute.
For patients being discharged home, education should be given to monitoring their pulse before every dose of Digoxin and if pulse < 60, to hold the medication and call their doctor (Choice B). The patient should also be educated that vision changes like yellow-green color distortions may be a sign of early toxicity, and the patient should call the prescribing physician as soon as possible so the cause can be determined. Digoxin can be held early ( Should call the prescribing physician rather than the eye doctor, Choice A reflects an incorrect statement by the patient).
Some patients are prone to digoxin toxicity more than others:
Certain electrolyte imbalances such as Hypokalemia (< 3.5 mEq/L); Hypercalcemia (>10.2 mg/mL) and Hypomagnesemia (<1.5 mg/dL) can increase the toxicity. So, patients who are on diuretics concomitantly for heart failure are prone to more side effects because diuretics tend to cause hypokalemia(Choice E). Such patients need to be educated regarding consuming adequate potassium-rich diets(Choice D). Any action that precipitates hypercalcemia should be avoided because high calcium increases toxicity (there is no need to increase calcium intake significantly, Choice C reflects an incorrect statement by the patient). Elderly patients are at more risk for toxicity because they have an age-dependent decrease in liver and kidney functions. Digoxin is metabolized via liver and kidney, so lower kidney/ liver function predisposes to toxicity. Patients taking calcium channel blockers (CCBs) are also at risk for digoxin toxicity.
The nurse should also be aware of specific over the counter medications that may precipitate digoxin toxicity and educate patients accordingly. These include a. Ephedra that increases cardiac stimulation b. Licorice extract (Choice F) acts as hormone aldosterone - causing sodium and water retention and growing potassium loss. Hypokalemia, in turn, precipitates digoxin toxicity.
This video below will provide a quick summary of all you need to know about Digoxin for NCLEX:
https://player.vimeo.com/video/409317953
Which of the following maternal deficiencies may result in neural tube defects in a fetus?
A. Folic acid
B. Vitamin B12
C. Vitamin E
D. Iron
Explanation
The correct answer is A.Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the machine to close. B, C, and D are incorrect. Neither of these answer options is associated with neural tube defects.
Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. When the neural tube does not close completely, a neural tube defect develops. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly.
Neural tube defects are considered a complex disorder because they are caused by a combination of multiple genes and multiple environmental factors. Known environmental factors include folic acid, maternal insulin-dependent diabetes, and maternal use of certain anticonvulsant (antiseizure) medications. While only a few environmental factors have been characterized, many different studies provide evidence that NTDs have a genetic component in their development. Studies of twins with NTDs have shown both identical twins have NTDs more than both fraternal twins. Studies of families show that the chance of having a second family member born with an NTD after one child is born with an NTD increase. For example, the general population’s chance of having an NTD is approximately 0.1% (1 in 1000). However, once the couple has one child with an NTD, their chance of having a second child with an NTD is increased to approximately 2-5%. Further studies have shown evidence for a genetic pattern of inheritance for NTDs.
NTDs are a feature (or symptom) of known genetic syndromes, such as trisomy 13, trisomy 18, specific chromosome rearrangements, and Meckel-Gruber syndrome.
Which of the following obstetrical procedures can be used to assist the head of the fetus during vaginal delivery? Select all that apply.
A. Amniotomy
B. Forceps assisted delivery
C. External version
D. Vacuum assisted delivery
Explanation
Choices B and D are correct.
Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant.
Choice A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps to induce labor but does not assist in the delivery of the head of the fetus.
Choice C is incorrect. The external version is a technique used when the baby is not in an appropriate position for vaginal delivery. The external cephalic version is used to turn a fetus from a breech position or side-lying (transverse) position into a more favorable head-down (vertex) position to help prepare the baby for a vaginal delivery. The external version is typically done before the labor begins, often around 37 weeks. Occasionally, it is done during the labor but before the membranes have ruptured. If the amniotic sac has ruptured or if there is not enough amniotic fluid around the fetus (oligohydramnios), version must not be done as it may end up injuring the fetus. Version does not directly assist in the delivery of the head of the fetus.
Which of the following medications does the Obstetrics nurse expect to be ordered for the patient who is experiencing hypotonic labor?
A. Oxytocin
B. Fentanyl
C. Magnesium sulfate
D. Betamethasone
Explanation
Answer: A
A is correct. Because this patient is in hypotonic labor, meaning she is not having contractions that are strong and coordinated enough for her work to progress, she needs intervention. Oxytocin, or Pitocin, is the medication that will strengthen contractions by stimulating the muscles of the uterus. The nurse expects this medication to be ordered for her patient in hypotonic labor.
B is incorrect. Fentanyl is an opioid used for severe pain. This medication may be used in an epidural for a laboring patient, but it would not be indicated for hypotonic labor.
C is incorrect. Magnesium sulfate is a medication used in preterm labor to help stop contractions. It would be contraindicated in the patient experiencing hypotonic labor.
D is incorrect. Betamethasone is a steroid administered to mothers in preterm labor to help the development of the fetus’s lungs in anticipation of preterm delivery. It would not be indicated for hypotonic work.
The nurse is preparing ephedrine nasal spray for a client in the medical ward. The nurse understands that ephedrine is contraindicated in which of the following patients?
A. A client with pheochromocytoma
B. A client with bronchial asthma
C. A client with allergic rhinitis
D. A client with hypotension due to sepsis
Explanation
Choice A is correct. A Pheochromocytoma is a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine. Clinical manifestations of pheochromocytoma include paroxysmal hypertension, episodic headache, sweating, and palpitations. Ephedrine is an adrenergic agonist and is often, used as a nasal decongestant. It is also used to prevent low blood pressure during spinal anesthesia.
In pheochromocytoma, there is a systemic overload of catecholamines. Ephedrine is contraindicated in clients with pheochromocytoma because it may lead to further exacerbation of adrenergic activity which could be fatal.
Choice B is incorrect. Ephedrine is indicated in bronchial asthma as it stimulates the dilation of the bronchial muscles by stimulating the beta receptors found in the bronchus.
Choice C is incorrect. Ephedrine is used in allergic rhinitis because it may serve as a nasal decongestant due to its vasoconstrictive effects.
Choice D is incorrect. Adrenergic agonists such as ephedrine are used in hypotension due to its sympathomimetic effects on the body leading to increased blood pressure. Ephedrine is often used to prevent low blood pressure during spinal anesthesia.
The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply.
A. Urinary incontinence.
B. Pupil constriction.
C. Diarrhea.
D. Altered level of consciousness (LOC).
E. Constipation.
Correct Answers: B, D, E
Explanation
Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, Altered level of consciousness, and Pupil constriction and urinary retention.
Diarrhea and urinary incontinence are not expected while a client is receiving hydromorphone.
What behavior would the nurse expect to see in a couple that is over the age of 35 and expecting a baby?
A. Increased financial concern related to costs associated with the birth
B. Increased confidence related to previous childbirth experiences
C. Increased anxiety of physical risk related to maternal age
D. Moderate anxiety related to uncertainty about the fetal well being
Explanation
Advanced maternal age for childbearing has been traditionally set at 35 years old, although the average age for a first pregnancy in the United States has been increasing in recent years. Some of the reasons women delay pregnancy are that they want to be in a stable relationship, they have fertility problems, or they want to be established in their careers. An advanced maternal age for childbearing is seen by healthcare professionals to be correlated with poorer outcomes in pregnancy. This may be because of a higher incidence of chronic medical conditions among
The correct answer is D. In addition to nursing diagnoses applicable to all pregnant women, the expectant couple over the age of 35 may have additional concerns about the well-being of their baby as it relates to Down syndrome or other genetic disorders. A is incorrect. Most couples over the age of 35 are more financially secure and have fewer concerns related to the cost of birth. B is incorrect. Couples over the age of 35 may have experienced infertility problems, births many years before, or have had problem births. C is incorrect. Maternal age may affect how well a woman can physically cope with pregnancy and childbirth.
The nurse is administering eye drops to a client diagnosed with conjunctivitis. Place the following steps in the correct sequence for the nurse to perform appropriate eye drop administration:
Pull down the lower eyelid
Administer the medication in the center of the lower eyelid
Tilt the patients head back
Ask the patient to close their eyes
Explanation
First: tilt the client’s head back.
Second: pull down the lower eyelid, thus creating a pocket in which to administer the medication.
Third: administer the medication in the center of the lower eyelid where the pocket was created by pulling down the lower eyelid.
Fourth: ask the client to close their eyes (without squeezing) for 1-3 minutes to allow the eye drops to fully absorb.
A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective?
A. “At around the time I would normally have my period, I should abstain from intercourse.”
B. “I should no longer have sex during the last trimester of pregnancy.”
C. “My sexual desire will remain the same for the entire pregnancy.”
D. “The best time to enjoy sex is in the second trimester.”
Explanation
Correct Answer is D. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities.
Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present.
Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well being and the presence of certain discomforts brought about by the pregnancy. It is not the same throughout pregnancy.
The mother of a 2-month old infant tells the nurse that her mother-in-law said to her that picking her baby up immediately when she cries, “spoils her baby”. What would be the nurse’s best response?
A. “You can let your baby wait a while before picking her up.”
B. “Babies need to be cuddled and comforted; this does not spoil your child.”
C. “You need to feed her right away because crying means that they are hungry.”
D. “You can just let your baby cry; she will stop once she gets tired.”
Explanation
Choice B is correct. Infants need to have their security needs met by being held and cuddled.
A is incorrect. Not picking up the baby after she has cried does not meet the baby’s need for security.
C is incorrect. Infants cry for many reasons. Assuming that the child is hungry and feeding them each time they cry may cause overfeeding problems such as obesity.
D is incorrect. Letting the baby cry to sleep does not meet the baby’s security needs.
A client diagnosed with acute gastroenteritis is prescribed 30mEq of oral potassium chloride twice daily for hypokalemia. The nurse should implement which nursing intervention in administering the medication:
A. Sprinkle contents of capsule on apple sauce to increase palatability
B. Crush the extended release tablet to improve palatability
C. Give potassium supplements separate from other medications.
D. Give potassium 2 hours before meals.
Explanation
Choice A is correct. Potassium supplements can have an inferior taste. To improve palatability, the nurse may sprinkle the contents of the potassium capsule on apple sauce, and the client can swallow it. The client must not chew on a capsule or tablet.
Choice B is incorrect. Breaking or crushing the potassium tablet may cause too much of the drug to be released at one time. An extended-release tablet should never be crushed.
Choice C is incorrect. Potassium can be given with other medications. It is not necessary to give potassium alone.
Choice D is incorrect. They are giving potassium two hours before meals are typically the same as providing it on an empty stomach, which predisposes the client to be esophageal and gastric irritation. Potassium is irritating to the esophagus and the stomach. Potassium should not be given on an empty stomach. It is best tolerated when given with food.
Upon noticing fetal bradycardia, the labor and delivery room nurse performs a vaginal examination on her client in labor. She discovers a pulsatile mass. What is the initial action of the nurse?
A. Prepare for a Cesarean section.
B. Tell the client not to push when contractions arrive.
C. Escort the father out of the room.
D. Place the client in Trendelenburg position.
Explanation
Choice D is correct. Cord prolapse is a condition where the umbilical cord descends before or with the fetal presenting part. It should be suspected when there is a non-reassuring fetal heart rate tracing and absent membranes. A digital vaginal exam or external inspection will help the nurse confirm the suspicion of cord prolapse. The diagnosis is confirmed by palpating a pulsatile mass in the vaginal vault.
In this condition, the presenting fetal part puts pressure on the prolapsed cord, compromising the fetal blood supply. Additionally, fetal blood flow is further compromised by umbilical vasospasm that occurs due to exposure to the cold atmosphere. Compromise of fetal blood supply results in fetal hypoxia and non-reassuring fetal heart rate pattern (Fetal bradycardia or recurrent, variable decelerations). The Trendelenburg position makes use of gravity to pull the embryo back into the uterus, relieving pressure off the umbilical cord from the presenting part.
Cord prolapse is an obstetric emergency. The nurse should suspect it if fetal bradycardia or variable decelerations occur especially, immediately after the rupture of membranes. The nurse should:
Call for help Avoid handling the cord, as it can cause further vasospasm and worsen outcomes. Manually lift the presenting part off the cord by vaginal digital exam. Do not push the cord back. Place the client in the left-lateral, Trendelenburg position, with head down and a pillow placed under the left hip. Prepare for immediate delivery ( usually via. emergency Cesarean section). If delivery is not immediately available and fetal decelerations persist, consider tocolysis ( eg: terbutaline) while awaiting the Cesarean section. Tocolytics relax the uterus, stop contractions, and therefore, relieve some pressure off the cord.
Choice A is incorrect. With the fetus in distress, the nurse should prepare for an emergency C-section; however, this is not the first action of the nurse.
Choice B is incorrect. In cord prolapse, the primary goal of the nurse is to ensure that the fetal blood supply and fetal oxygenation is restored. Telling the client not to push during contractions is an inappropriate action.
Choice C is incorrect. The nurse may ask the client’s husband to leave, especially if they are disruptive. However, this is not the primary concern at this moment.
Here is a short 2-minute video on Dos and Don’ts of umbilical cord prolapse :
https://youtu.be/iYDdB1K46wk
While in the OBGyn clinic, your client tells you that this is her 4th pregnancy. She had an abortion of her first pregnancy at 22 weeks. Her second pregnancy was twins, born at 25 weeks, and they passed away in the NICU shortly after their delivery. Her third pregnancy was a boy born at 32 weeks, healthy. She is currently 30 weeks pregnant. Which of the following describes your patient?
A. G2T4P0A0L2
B. G4T0P3A0L1
C. G4T0P4A0L1
D. G4T0P3A1L1
Explanation
Choice B is correct. This describes your patient: she has been pregnant four times (G4), had 0 term births (T0), three preterm births (P3), 0 abortions (the fetus that is aborted after 20 weeks, spontaneously or electively, is counted as premature birth, and P will increase but A and L will not) and has one living child (L1). The GTPAL acronym is commonly used to describe pregnancy outcomes:-
The G stands for gravidity, the number of times that the patient has been pregnant. This includes current pregnancies, so for this question, it is 4. The T stands for term births or the number of births occurring at 37 weeks gestation or later. In this question, the patient has had no births at term, so for T, we have a 0. The P stands for preterm births or the number of births occurring before 37 weeks. For this question, the patient had twins at 25 weeks, so she gets P1 for twins, a baby boy at 32 weeks, and had an abortion after 20 weeks. Hence, she gets a total of 3 preterm births or 3 for “P.” Note: Multiple births (twins, triplets, and higher multiples) count as one pregnancy (gravidity – G1) and as one birth (P1 or T1 based on whether twins/triplets are pre-term or term). The A stands for abortions or miscarriages. The "abortions" number refers to the total number of spontaneous or induced abortions and miscarriages, including ectopic pregnancies, before 20 weeks. If a fetus is aborted after 20 weeks, spontaneously or electively, it is counted as premature birth, and P will increase, but A and L will not. If the abortion occurred before 20 weeks, count it under ‘A’ and ‘G.’ If the abortion happened after 20 weeks, count it under ‘P’ and ‘G.’ For this patient, she had one abortion. It happened after 20 weeks, so it gets counted under the G and P sections but not under “A.” Lastly, L stands for the current number of living children. She tells us her twins passed away in the NICU, and her baby boy from her third pregnancy lives at home, so she gets a 1 for ‘L.’
Choice A is incorrect. This patient has been pregnant two times, had four term births, no preterm births, no abortions, and has two living children.
Choice C is incorrect. This patient has been pregnant four times, had 0 term births, four preterm births,0 abortions, and has one living child.
Choice D is incorrect. This patient has been pregnant four times, had no term births, three preterm births, one abortion (likely occurred before 20 weeks as it is not counted here under P), and has one living child.
While reviewing fetal monitoring strips, the labor and delivery nurse notes that the piece is nonreassuring. What features characterize a fetal monitoring strip as nonreassuring? Select all that apply.
A. Fetal heart rate less than 110 beats/minute.
B. Increase in variability.
C. Late decelerations
D. Mild variable decelerations
Explanation
Answer: A and C
A is correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring.
B is incorrect. An increase in variability is a reassuring factor. A decrease in variability would be nonreassuring.
C is correct. Late decelerations are an ominous sign, and immediate interventions should be taken to improve the fetal heart rate. They are characteristic of a nonreassuring heart rate.
D is incorrect. Mild, variable decelerations are okay, only when the variable decelerations are severe are they nonreassuring.
The nurse is administering medications to a 5 year old client diagnosed with pneumonia. The health care provider has ordered a cough suppressant. Which medication does the nurse administer?
A. Dextromethorphan
B. Guaifenesin
C. Dexmedetomidine
D. Protonix
Explanation
Answer: A
A is correct. Dextromethorphan is a cough suppressant. It is the ingredient in many over the counter cough medicines such as Delsym, Robitussin, and NyQuil. Dextromethorphan works by signaling the brain to stop triggering the cough reflex.
B is incorrect. Guaifenesin is an expectorant, not a cough suppressant. Unlike a cough suppressant, Guaifenesin loosens the congestion in a client’s chest and throat making it washer for them to cough out mucus and phlegm.
C is incorrect. Dexmedetomidine is a sedative medication. It activates receptors in the brain that inhibits neuronal firing, which causes sedation. It is not a cough suppressant.
D is incorrect. Protonix is a proton pump inhibitor used to decrease the amount of acid produced by the stomach. It is not a cough suppressant.
Place the following items in the correct sequential order from the most reliable and accurate indication of pain to the least competent, precise evidence of torture. Physiological indicators of pain Conditions that can lead to pain Self-reports of pain using a pain scale Behavioral indicators of pain
Explanation
The most reliable and accurate indication of pain is the client’s self-report of pain using a pain scale and with other mechanisms such as narrative accounts of torture, including sensory and emotional descriptors.
The second most pain scale reliable and accurate indication of pain is the client’s current conditions that can lead to anxiety; the third most reliable and dependable evidence of pain is the client’s behavioral indicators of illness; and, of the above choices, the client’s physiological signs of illness are the least reliable and least accurate indication of illness.
Which of the following are invasive procedures not routinely done on all pregnant women? Select all that apply.
A. Contraction stress test
B. Amniocentesis
C. Nonstress test
D. Nitrazine test
Correct Answers are A and B.
A is correct. In a contraction stress test, contractions are induced with oxytocin. This is only done if a nonstress test is nonreactive, or there are other concerns.
B is correct. An amniocentesis is a sampling of amniotic fluid that is sent for genetic testing. This is only done if indicated.
C is incorrect. A nonstress test is noninvasive and done as routine antepartum testing.
D is incorrect. While an atrazine test is not routinely done on all pregnant women, it is not invasive. Please note the question is asking to name the “non-routine” and “invasive” tests. Nitrazind test refers to the testing of the pH of vaginal secretions to determine if they are amniotic fluid, and there has been a rupture of membranes.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
The nurse is preparing a 3-year-old child for an incision and drainage of large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?
A. Peripheral nerve block
B. Spinal anesthesia
C. General Anesthesia
D. Local Anesthesia
Explanation
Choice C is correct. A large leg abscess will need significant time for incision and drainage (I and D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed.
Choice A is incorrect. A peripheral nerve block will not be able to provide adequate anesthesia to proceed with I and D procedure of a large leg abscess. For the child to cooperate with such surgery, sedation is necessary. General anesthesia provides necessary analgesia and sedation to the child.
Choice B is incorrect. Although spinal anesthesia may achieve analgesic effect, the child still may not cooperate with the surgical procedure because spinal anesthesia does not provide sedation.
Choice D is incorrect. Local anesthesia is helpful while addressing small abscesses. A large abscess requires more time and needs the child to cooperate. Children undergoing such procedures require general anesthesia to provide necessary sedation as well because this minimizes their fears of intrusive or mutilating procedures.
Reference:
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
The equianalgesic chart on the wall of the medication room states that 10 mg of IV morphine is equivalent to 7.5 mg of oral hydromorphone in terms of potency. Your client has been effectively treated with 80 mg of IV morphine. Calculate and fill in the blank with the equianalgesic dose of oral hydromorphone.
______ mg of Oral Hydromorphone ( Please enter numeric only).
Explanation
The correct answer is 60mg of oral hydromorphone.
The calculation of the equianalgesic of oral hydromorphone, when compared to IV morphine, should be made based on known equivalent potency. The potency of 10 mg of IV morphine is equivalent to that of 7.5 mg of oral hydromorphone.
10 mg IV Morphine = 7.5 mg Oral Hydromorphone.
1 mg of IV Morphine then equals 0.75mg of Hydromorphone ( 7.5/10) so Equi-analgesic factor = 0.75.
Multiply IV morphine dose with Equi-analgesic factor to arrive at oral hydromorphone dose.
80 mg IV Morphine = 80 x 0.75mg oral Hydromorphone= 60 mg of oral hydromorphone.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.
The nurse administers bumetanide (Bumex), a loop diuretic, to a client with pulmonary edema. The nurse should watch out for which symptom that indicates a complication to the medication?
A. Distended neck veins.
B. Crackles and rhonchi.
C. Painful leg cramps.
D. Increase in urine output.
Explanation
Choice C is correct. Leg cramps may occur due to a low potassium level (hypokalemia), a common complication of loop diuretics.
A is incorrect. Distended neck veins may indicate fluid overload, CHF, or a Cardiac tamponade. Fluid overload and CHF may be indications for administration of the drug but is not a complication.
B is incorrect. Crackles and rhonchi are manifestations of pulmonary edema and fluid in the alveoli. Diuretics may be administered to relieve these symptoms, but these are not complications of the drug.
D is incorrect. An increase in urine output is the desired effect of the medication, not its complication.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier
The nurse is observing a client who has been in labor for 16 hours. For which of the following observations, should she notify the healthcare provider? Select all that apply.
A. FHR 170-200 for 20 minutes
B. Early decelerations
C. Variable decelerations
D. Moderate variability
Explanation
Answer: A and C
A is correct. A Fetal Heart Rate of 170-200 for 20 minutes is fetal tachycardia and should be reported to the healthcare provider. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention.
B is incorrect. Early decelerations do not need to be reported to the healthcare provider. They occur when the fetal heart rate decreases at the same time as a contraction, and are followed by a return to baseline. They occur due to the pressure of the fetus’s head on the pelvis or soft tissue, and the nurse requires no intervention after an early deceleration.
C is correct. Variable decelerations need to be reported to the healthcare provider immediately. They are sharp, and profound drops in the fetal heart rate unrelated to the time of contractions are a non-reassuring sign on a fetal heart rate strip. Variable decelerations are caused by cord compression, such as a prolapsed cord, and are an emergency requiring quick nursing intervention.
D is incorrect. Moderate variability does not need to be reported to the healthcare provider. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. A moderate amount of variability is what is expected, and is considered a reassuring sign.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Subject: Maternity Nursing
Lesson: Problems with Labor and Delivery
Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.
The nurse is administering digoxin to her 11-year-old patient with congestive heart failure. She knows to verify the pulse rate before administering the medication and holds it for a pulse less than _________.
Explanation
Answer: 70
In children, the nurse should hold digoxin at a heart rate of less than 70. Digoxin is a cardiac glycoside that lowers the heart rate. Therefore, it should not be administered if the heart rate is already low to prevent severe bradycardia.
The nurse should always check her order parameters to ensure the drug is being properly administered. Always, before giving Digoxin, the nurse should check the apical pulse for 1 complete minute. The apical pulse rate at which the nurse should hold digoxin differs based on age because the normal reference heart rate is higher in infants and children. In infants, the nurse should hold digoxin for an apical pulse <90. In older children, such as this question asked, the nurse should hold digoxin for an apical pulse < 70. In an adult, hold digoxin for an apical pulse <60. Then, the nurse should notify the physician because the physician may want to investigate if the patient is experiencing digoxin toxicity.
NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies
You are caring for a pregnant woman with a baseline BMI of 22. Your education for this client is that a desirable weight gain during pregnancy with one baby for her is:
A. 28 to 40 pounds
B. 25 to 35 pounds
C. 15 to 25 pounds
D. 11 to 20 pounds
Explanation
The Correct Answer is B (25 to 35 pounds).
The amount of optimal weight gain during pregnancy is determined based on the woman’s body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height.
A baseline BMI of 22 indicates that this woman’s baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds.
Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother.
Gaining too little weight can lead to premature birth and low infant birth weight. Gaining too much weight can also result in premature birth and obesity of the child in later life. Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding.
Choice A is incorrect. This is the recommended weight gain during singleton pregnancy for an underweight woman.
Choice C is incorrect. This is the recommended weight gain during singleton pregnancy for an overweight woman.
Choice D is incorrect. This is the recommended weight gain during singleton pregnancy for an obese woman.
NCSBN Client Need
Topic: Reduction of Risk Potential; Sub-topic: System-Specific Assessment.
The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on Nifedipine. His home medications include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding Nifedipine? Select all that apply
A. “If I get ankle swelling with this medication, furosemide will help.”
B. “My gums may swell because of this medication.”
C. “I will avoid getting up too quickly from sitting or lying position.”
D. “I will check my pulse daily as the drug may significantly slow my heart rate.”
E. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.”
F. “It is highly likely that I will get constipated from this drug.”
G. “My heartburn may worsen with this medication.”
H. “If I get cough and tongue swelling, I will hold Nifedipine”
Explanation
Correct answers are A, D, E, F, and H. Calcium channel blockers (CCBs) are very commonly used to treat hypertension. The nurse needs to be aware of the common side effects of calcium channel blockers and educate the clients appropriately. There are two classes of calcium channel blockers: Dihydropyridines and Non-dihydropyridines.
Dihydropyridines, including nifedipine and amlodipine, are more selective to blood vessels (potent vasodilators) and have little or no effect upon cardiac contractility/ conduction. These are used to treat hypertension or chronic stable angina. Significant side effects include dose-dependent pedal edema, headache, flushing, and orthostatic hypotension.
Non-dihydropyridines, including verapamil and diltiazem, are less vaso-selective (less potent vasodilators) but more cardio-selective (depress cardiac conduction and contractility). These are used to treat cardiac arrhythmias, hypertension, chronic stable angina. Significant side effects include dose-dependent constipation, bradycardia, and reduced cardiac output.
Their mechanisms of action explain their different side effect profiles.
Dihydropyridines like Nifedipine cause peripheral edema in 20 to 30 percent of clients. The mechanism of this edema involves the redistribution of fluid from the intravascular compartment into the interstitial compartment. Therefore, this edema is not from fluid retention or increased plasma volume. Diuretic therapy with Furosemide will not help treat this pedal edema. Therefore, Choice A does not reflect correct understanding by the client and needs additional teaching. Since this edema is dose-dependent, it is often treated by a reduction in dose of the CCB. Rather than just taking other furosemide, the client needs to contact the healthcare provider so the edema can be addressed with dose adjustment. Dihydropyridines like Nifedipine have minimal effect on cardiac contractility or conduction. They do not cause bradycardia. On the contrary, they may cause reflex tachycardia due to vasodilation. Therefore, Choice D does not reflect correct understanding by the client and needs additional teaching. Please note that because of their cardo-selectivity and suppressive effect on contractility/ conduction, Verapamil and Diltiazem cause bradycardia and decreased cardiac output (seen in 25% patients on Verapamil). While IV calcium gluconate/ calcium chloride is often used to treat toxicity from calcium channel blockers, there is no evidence to say oral calcium supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching. Constipation is a more common side effect with Non-Dihydropyridines like Verapamil (20% incidence). Illness is less common with Dihydropyridines. While there is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the client is highly likely to get constipated from Nifedipine. Therefore, Choice F does not reflect correct understanding by the client and needs additional teaching. It is those Clients that are on Verapamil that need to be instructed to increase their fiber intake significantly. Constipation with Verapamil is dose-dependent. Cough and tongue swelling (Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI), which may lead to this side effect, so the nurse will need to explain this to the client. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching.
Choice B is incorrect. Choice B reflects a correct understanding and does not need additional teaching. Gum/ gingival hyperplasia is familiar with extended-standing use of Nifedipine. Both Dihydropyridines and Non- Dihydropyridines may cause this. It is more common with Nifedipine than with Amlodipine.
Choice C is incorrect. Because of peripheral vasodilation, Dihydropyridines like Nifedipine cause postural or orthostatic hypotension. So, the client should be aware of getting up slowly from the lying/ sitting position (Choice C), so they do not become dizzy. Choice C reflects a correct understanding and does not need additional teaching.
Choice G is incorrect. All calcium channel blockers reduce the pressure in the lower esophageal sphincter exacerbating heartburn. This effect is seen more with Amlodipine/ Nifedipine. Of all the CCBs, Diltiazem is least likely to increase reflux symptoms. Therefore, it may be more appropriate to prefer diltiazem over other CCBs in patients with moderate to severe heartburn. Choice G reflects a correct understanding and does not need additional teaching.
Test-taking strategy: While answering the questions that ask about “need for additional teaching regarding the medication,” always look for negative options ( the options that reflect incorrect understanding) in the list.
NCSBN client need.
Topic: Pharmacological and parenteral therapies; Sub-Topic: Adverse effects of medications.
Which of the following medication classes are considered ‘quick-relief’ or ‘rescue medications’ for a child having an acute asthma attack? Select all that apply.
A. Corticosteroids
B. Leukotriene modifiers
C. Short-acting beta 2 agonists
D. Anticholinergics
Explanation
Choices C and D are correct.
C is correct. Short-acting beta-2 agonists are “rescue” medications used for bronchodilation in an acute asthma attack. Examples include albuterol and salbutamol. A “rescue” medication is the one that can provide relief even after bronchospasm is triggered.
D is correct. Anticholinergics are rescue medications used for the relief of acute bronchospasm. Examples include Ipratropium and Tiotropium.
A is incorrect.Corticosteroids are long term control medications used to reduce inflammation. They are not immediately useful as “rescue” medications but are useful in long term management of persistent asthma.
B is incorrect.Leukotriene modifiers are long term control medications used to prevent bronchospasm and inflammatory cell infiltration. They are often used as prophylactic agents before a triggering event, for example, in exercise-induced asthma. They are not useful as a “rescue” once bronchospasm occurs.
For example, Montelukast is indicated to be used “ as needed” before exercising in patients who do not require daily bronchodilator. Montelukast is taken at least two hours before the initiation of exercise.
The nurse is caring for four newborns during her shift in the unit. After performing an assessment, which newborn should the nurse give her attention to?
A. A 24 hour old newborn that has not yet passed meconium.
B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL.
C. A 3 hour old infant that has just passed meconium
D. A 5 day old infant with a positive Babinski reflex
Explanation
Correct Answer is A.A newborn that has not yet passed meconium after 24 hours should be evaluated for Hirschsprung’s disease.
Choice B is incorrect. An infant with slight jaundice after the first 24 to 48 hours of life should not cause concern to the nurse. The physician should be notified if the disease occurs within the early 24 hours to evaluate if the jaundice is pathological. Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5 mg/dL/day or absolute level at anytime higher than 17 mg/dL, or an infant has signs and symptoms suggestive of serious illness
Choice C is incorrect. This is entirely normal as meconium is expected to be passed within the first 24 hours of the child’s life.
Choice D is incorrect. Babinski reflex is a primitive reflex that is present in newborns. The nurse should not be concerned about this assessment finding.
Reference:
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003.
SORRY MISSED TO COPY THE CORRECT QUESTION
SORRY MISSED TO COPY THE CORRECT QUESTION
Explanation
Choice C is correct. The nurse acknowledges the patient’s emotions and educates the patient regarding the situation. False reassurance is not given, and client expectations are set. The client’s age and the symptoms she has been experiencing over the last few months indicate that she is likely peri-menopausal or post-menopausal. Pregnancy around such age is unusual.
Some post-menopausal women have elevations in β-hCG that may cause the serum and urine pregnancy tests to be reported as positive; however, such patients are not pregnant. Since false-positive pregnancy tests can occur, an ultrasound would be helpful to confirm. Alternatively, serial serum β-hCG can be performed to see if there is an expected increasing trend with the progression of pregnancy. The absence of such a serial increase indicates a false-positive test.
Choice A is incorrect. The nurse is still unsure whether the client is pregnant. Clients undergoing menopause tend to have a false-positive pregnancy test due to high levels of g. The nurse should not jump to conclusions which may give the client a false reassurance.
Choice B is incorrect. The nurse’s response to the client is inappropriate. The response conveys a sense of ridicule to the patient and challenges the patient.
Choice D is incorrect. A repeat urine pregnancy test is still likely to be positive. The nurse should acknowledge the client’s feelings and should tell her that a confirmatory test early in pregnancy is an ultrasound. Alternatively, serial serum β-hCG can be performed to see if there is an expected increasing trend with the progression of pregnancy. The absence of such a serial increase indicates a false-positive test.
While reviewing medication-related hematological side effects, the nurse recognizes which of the following as the most severe form of bone marrow toxicity:
A. Aplastic anemia
B. Leukocytosis
C. Thrombocytosis
D. Granulocytosis
Explanation
Choice A is correct. Aplastic anemia leads to pancytopenia, a severe decrease in all hematological cell types: red blood cells, white blood cells, and platelets. Aplastic anemia may be caused by primary bone marrow failure or from secondary causes such as medications. Some medications that cause aplastic anemia include chloramphenicol, phenylbutazone, sulfonamides, anticonvulsants, cimetidine, and NSAIDs. Drug-induced aplastic anemia is the result of an idiosyncratic hypersensitivity reaction and is often reversible. In such drug-related aplastic anemias, the nurse must notify the physician and withdraw the offending agent.
Choice B is incorrect. Leucocytosis refers to increased white blood cells. Leucocytosis can be induced by some medications (for example, Lithium); however, it is not serious bone marrow toxicity. Instead, Leukopenia (a reduced number of white blood cells) is more serious and makes the patient susceptible to infection.
Choice C is incorrect. Thrombocytosis refers to increased platelet count. It is not the most serious form of bone marrow toxicity. Severe Thrombocytopenia (a reduced number of platelets) is more serious as it causes the blood not to clot as easily and increases bleeding risk.
Choice D is incorrect. A granulocyte is a type of white blood cell. White blood cells are classified into two types: granulocytes ( neutrophils, eosinophils, basophils) and agranulocytes ( monocytes, lymphocytes). Granulocytosis is an elevated granulocyte count. Granulocytosis may be seen as the body responds to an infection. However, it is not as serious as agranulocytosis. Agranulocytosis ( granulocytopenia) is a more serious disorder that causes a severe decrease in the neutrophil count and predisposes the client to severe infections. Medications that cause agranulocytosis include antithyroid medications (carbimazole and methimazole); anti-inflammatory medications (sulfasalazine, nonsteroidal anti-inflammatory drugs (NSAIDs)), and some antipsychotics (clozapine)
NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological Therapies
You are working in the intensive care nursery and are assigned to take care of an infant withdrawing from cocaine. At your first assessment, you appreciate the following: a high pitched cry, no tremors, increased muscle tone, sleeping for 3 hours in between feedings, no congestion, respiratory rate = 42. excessive sucking on the pacifier, poor nutrition, no vomiting, and no loose stools. What is the Neonatal Abstinence (NAS) score for this patient?
A. 7
B. 12
C. 2
D. 8
Explanation
Choice A is correct.
Neonatal abstinence syndrome (NAS) occurs due to sudden withdrawal of the fetus due to the discontinuation of substances used/abused by the mother during pregnancy. The Finnegan scoring system is commonly used to assess the severity of NAS. The NAS score uses 21 symptoms that are most seen in opiate-exposed infants. A numerical score is assigned to each sign and its corresponding severity. The total abstinence score is determined by the sum of the numerical score attached to each sign. This scoring can help guide initiation, monitoring, and cessation of treatment in the newborn.
The initial treatment of NAS includes nonpharmacological methods. If improvement not noted with nonpharmacological measures or if the infant develops severe withdrawal symptoms, pharmacological agents are used. NAS score helps in assessing the severity. The most common agent used in the treatment of NAS secondary to opioids is Morphine. The infant may breastfeed unless the mother is involved in polysubstance abuse or has HIV.
The Neonatal Abstinence Score (NAS score) uses 21 symptoms that are most seen in opiate-exposed infants. A numerical score is assigned to each withdrawal symptom and its corresponding severity. The total abstinence score is determined by the sum of the numerical score attached to each sign.
Each of these observations gives you a part of the NAS score for this infant:
High pitched cry = 2 points.
No tremors = 0 points
Increased muscle tone = 2 points
Sleeping for 3 hours in between feedings =0 points
No congestion = 0 points
RR = 42 = 0 points
Excessive sucking on the pacifier = 1 point
Poor feeding = 2 points
No vomiting = 0 points
No loose stools = 0 points
This adds up to a total of 7 points for the NAS score for this patient. A score of 7 is in the moderate range. Less than five is mild, 5-8 is average, 8-12 is severe, and greater than 12 is very critical. For a score of 7, a breakthrough dose of morphine may not be appropriate, but the infant may not be ready to wean down on their methadone further.
NCSBN Client Need:
Topic: Health Promotion and Maintenance
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences
Your client, who has chronic pancreatitis and gastroparesis, is complaining of a migraine headache. The doctor has ordered butorphanol orally as needed for pain. What would you do?
A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis.
B. Call the doctor and suggest rectal butorphanol because the client has pancreatitis.
C. Administer the butorphanol orally as ordered.
D. Administer the butorphanol transdermally for pain.
Explanation
Choice A is correct.
This is a client with chronic pancreatitis and gastroparesis and is complaining of a migraine headache.Butorphanol is available in the oral form, the transnasal form, the transdermal, and the parenteral form. You would call the doctor and suggest transnasal butorphanol because the client has gastroparesis. The doctor has ordered butorphanol orally as needed for pain.
Choice B is incorrect. Butorphanol is not available for rectal administration. Butorphanol is available only in the oral form, the transnasal form, and the parenteral form.
Choice C is incorrect. You would not administer the butorphanol orally for pain because this route is contraindicated among clients with gastroparesis.
Choice D is incorrect. You can not administer transdermal butorphanol without a doctor’s order. The doctor needs to be called to obtain such an order.
Reference:
Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
The nurse is providing discharge education regarding the client’s eye drop medications. Which of the following actions does the nurse instruct the client to implement to minimize the eye drops’ systemic effects?
A. Instill the drops before meals.
B. While instilling the drops, swallow several times.
C. Blink vigorously to after instilling the drops.
D. Place a finger over the inner canthus for 30 – 60 seconds after instilling the drops.
Explanation
Choice D is correct. Eye drops are often prescribed for their topical effects in relieving local eye conditions. Occasionally, side effects may occur due to systemic absorption of the active medication in the eye drop solutions. Certain precautions can help reduce systemic absorption and, thereby, minimize side effects. Mucous membranes of the eye serve as the routes of systemic absorption. Placing a finger over the inner canthus occludes the nasolacrimal duct preventing the eye drop solution from reaching the mucous membranes and being absorbed into the systemic circulation.
Choices A, B, and C are incorrect. These instructions do not help minimize systemic side effects of eye drops. Unlike orally administered medications, the absorption of instilled eye drops is not affected by gastric contents (Choice A). Swallowing at the time of instillation does not affect the absorption of eye drops (Choice B). Finally, blinking vigorously forces the solution out of the eyes, decreasing its local therapeutic effect and is not recommended (Choice C).
Reference
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins
One of the most severe side effects of selective serotonin reuptake inhibitors (SSRI) is a serotonin syndrome. While educating a patient who was just initiated on an SSRI, which of the following symptoms of serotonin syndrome should the nurse emphasize to the patient? Select all that apply.
A. Rapid heart beat
B. Muscle twitches
C. Sweating
D. Diarrhea
Explanation
Choices A and B are correct. Serotonin syndrome is a medical emergency. A persistent rapid heartbeat, muscle twitches or jerking of the muscles are typical symptoms of a serotonin syndrome. Such patients should seek medical attention immediately.
Choices C and D are incorrect. Sweating and diarrhea are common side effects of SSRIs, but these by themselves do not indicate serotonin syndrome. If the patient is experiencing these symptoms along with other symptoms/ signs such as rapid heartbeat and muscle twitching, then they should seek urgent medical attention.
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Pharmacological therapies
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.;Subject: Fundamentals;Lesson: Medication Administration
The nurse is preparing to administer Dopamine (Intropin) to a client intravenously. All of the following are precautions are to be taken when administering the medication, except:
A. Use caution in calculating and preparing doses of the drug.
B. Monitor patient response slowly (blood pressure, ECG, urine output, cardiac output).
C. Dilute the drug before use if it is not prediluted.
D. Have Phenylephrine on standby in case extravasation occurs.
Explanation
Choice D is correct. This is not the precaution a nurse needs to take because it represents an erroneous statement. Phentolamine should be on standby to save the vein in case of infiltration, not Phenylephrine.
Phentolamine is an antidote that counteracts the effects of Dopamine, Vasopressin, Norepinephrine, and Phenylephrine by causing vasoconstriction by alpha-receptor stimulation. Dopamine-induced extravasation can cause tissue injury with blanching and hematoma. Subcutaneous injection of phentolamine has been proven to be clinically effective in preventing tissue injury in the case of Dopamine or Vasopressin extravasation.
Choice A is incorrect. This is the precaution that the nurse should take. The nurse should use extreme caution when calculating and preparing doses of the drug because even small errors could have serious effects.
Choice B is incorrect. This is the precaution that the nurse should take. Monitoring the patient’s response to the medication ensures that the most benefit is achieved with the least amount of toxicity to the client.
Choice C is incorrect. This is the precaution that the nurse should take. Diluting the drug prevents tissue irritation on injection.
Reference:
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
The nurse is educating a patient who is taking phenytoin. To make sure phenytoin does not fail, which Over-The-Counter (OTC) medication should the nurse advise the patient not to take at the same time?
A. Acetaminophen
B. Ibuprofen
C. Calcium Carbonate
D. Ranitidine
Explanation
Correct Answer is C. Calcium Carbonate (Tums) should not be taken at the same time as Phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant, and not getting it at therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against concomitant use of antacids/ tums and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the times of intake of calcium carbonate and phenytoin by at least two to three hours.
Choice A is incorrect. Acetaminophen and Phenytoin can be taken together without any concern for therapeutic failure.
Choice B is incorrect. Ibuprofen and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin.
Choice D is incorrect. Ranitidine and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin. Ranitidine may, however, increase the effects of Phenytoin, and the patient should be monitored for any phenytoin related adverse effects.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Pharmacological Therapies
Reference: Core Concepts in Pharmacology (Holland/Adams)
A 14-year-old is admitted to the medical ward for status asthmaticus. He has put on IV Theophylline. Which manifestation would the nurse consider as a side effect of the drug?
A. Grand mal seizures
B. Palpitations
C. Sleeplessness
D. Headache
Explanation
Choice D is correct. Headache is one of the most common side effects of Theophylline. It is important to understand the difference between a side effect and drug toxicity, A side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity ( adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range.
A is incorrect. Seizures are a sign of toxicity of Theophylline, not just a common side effect.
B is incorrect. Palpitations and arrhythmias are a sign of theophylline drug toxicity as well
C is incorrect. Insomnia is not associated with theophylline.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins
The nurse is attending a client who is 20 weeks pregnant and has completed patient education. Which of the following statements by the client indicates that she has a good understanding of her baby’s development?
A. “My baby is able to breathe now.”
B. “My baby can open his eyes.”
C. “My baby is about 7 ½ inches long.”
D. “My baby has fully grown fingernails.”
Explanation
The correct answer is C. By 20 weeks gestation; the fetus is approximately 20cm long or 7 ½ inches. This statement reflects a proper understanding of the mother regarding fetal development and does not require further teaching.
Choices A, B, and D are incorrect.
There are several stages of fetal development. Pregnancy comprises first, second, and third trimesters. In the first trimester, critical events include changes to the fertilized cell and the development of major organs and structures. During the second trimester, the organs and structures continue to develop, and the woman becomes more aware of the growing fetus. During the third trimester, the fetus gains weight, matures, and prepares for life outside the uterus.
Fetal lungs do not begin the movements of respiration until 24 weeks. The placenta provides oxygen to the fetus, and the developmental function of the lungs for breathing does not occur until birth. Therefore, the statement in Choice A needs further teaching.
The fetus can open its eyes at 28 weeks gestation, not at 20 weeks. Therefore, the statement in Choice B needs further teaching.
Fingernails begin to grow at ten weeks gestation but are not complete until 38 weeks. Therefore, the statement in Choice D needs further teaching.
NCSBN Client Need
Topic: Health Promotion and Maintenance.
Reference:
Safe Maternity and Pediatric Nursing (Linnard-Palmer/Coats); Chapter 3: Human Reproduction and Fetal Development
The nurse is educating a pregnant client who is admitted with deep vein thrombosis in her left lower extremity. The client is at 24 weeks of gestation. The client is placed on Low Molecular Weight Heparin (LMWH). Which of the following statements by the client indicate(s) that she understands the education regarding LMWH?
A. “My blood thinner will be stopped soon after delivery.”
B. “Since I am on LMWH, I must have a planned cesarean section.”
C. “I hate injections. I will likely switch to Warfarin after delivery.”
D. “There is an increased risk of fractures with long term LMWH therapy.”
E. “If I notice blisters or black-red areas at the injection site, I will hold LMWH and immediately contact the doctor.”
F. “If I decide to switch to warfarin after delivery, I should not breastfeed.”
Explanation
Choices C, D, and E are correct. LMWH is the anticoagulant of choice during pregnancy because it does not cross the placenta, but one may switch to Warfarin in the post-partum period. While Warfarin is contraindicated during active pregnancy due to its potential to cause congenital fetal disabilities, maternal/fetal bleeding, and miscarriages, it is considered safe in the post-partum period. Warfarin is also safe in lactating/ breastfeeding women. The client will need a minimum of 3 to 6 months of anticoagulation and, therefore, will be requiring anticoagulation for a few weeks even after delivery. Additionally, the risk of recurrent venous thromboses is high up to 6 weeks post-partum. Since the client does not like injections, oral anticoagulation with Warfarin is an option for her after delivery (Choice C).
Long term treatment with LMWH may decrease bone mineral density (osteopenia, osteoporosis) and increases the risk of fractures (Choice D). For those with pre-existing osteoporosis and fracture risk, close monitoring is needed on long term LMWH therapy.
It is common to have some bruising and swelling at the injection site. However, the presence of blisters and necrotic areas (blackish-red central portion) at the injection site may serve as a warning sign of a complication known as Heparin-Induced-Thrombocytopenia (HIT). If the patient or the nurse notes necrotic areas at the injection site, the physician must be notified immediately, and LMWH must be discontinued(Choice E). HIT is a rare but dangerous complication with unfractionated and low-molecular-weight heparins. The body forms antibodies to heparin that may cross-react with platelet antigens and cause a drop in the platelets. Despite a decline in the platelet count, HIT is associated with the formation of thromboses (deep vein thrombosis and pulmonary embolism) because HIT antibodies disrupt and activate the clotting system. If HIT is confirmed, heparin should never be re-initiated. Other anticoagulants, such as Argotraban or Fondaparinaux, are used.
Choice A is incorrect. Anticoagulation will not be stopped soon after delivery. The client will need a minimum of 3 to 6 months of anticoagulation and, therefore, will be requiring anticoagulation for a few weeks even after delivery. Anticoagulation in a client with a history of venous thromboses should never be discontinued immediately after birth because there is a high risk of recurrent venous thromboses at least up to 6 weeks post-partum.
Choice B is incorrect. It is not mandatory that the patient have a cesarean section. Normal vaginal delivery is still possible with adequate planning. If the patient is in labor, she should hold LMWH and notify the physician immediately. LMWH should be held at least 24 hours before the planned delivery. If the client ended up receiving LMWH within 24 hours of delivery, she should not be given epidural or spinal anesthesia.
Choice B is incorrect. Warfarin is safe in lactating women as it does not pass into breast milk to any measurable level. The client should be encouraged to breastfeed. Both LMWH and Warfarin are safe to take when breastfeeding.
NCSBN Client Need:
Topic:Pharmacological therapies;Sub-topic:Adverse Effects/Contraindications/Side Effects/Interactions
The nurse had just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first?
A. A 3 hour old newborn weighing 6 pounds
B. A 4 hours old newborn delivered at 42 weeks
C. A 6 hour old newborn 21 inches long
D. An 8 hour old newborn delivered at 40 weeks
Explanation
Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother’s last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemia and hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. A 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first.
Choice A is incorrect. According to the World Health Organization (WHO), the average birth weight for full-term babies is around 7.5 lb. However, a birth weight range between 5.5 lb. (2.5 kg) and 8.2 lb. (4.0 kg) is considered normal. Small for gestational age (SGA) is defined as a birth weight of less than 10th percentile for gestational age. Large for gestational age (LGA) refers to a birth weight equal to or more than the 90th percentile for a given gestational age. Macrosomia refers to a birth weight greater than 4000 to 4500 grams ( 4 to 4.5 kg), regardless to gestational age. The infant weighing 6 pounds ( Choice A) is within the normal weight range for a newborn; the nurse does not need to see this infant first.
Choice C is incorrect. The average length of full-term babies at birth is 20 inches (50 cm). The normal range is between 18 to 22 inches. Macrosomia is defined based on the birth weight, not the birth length. Twenty-one inches is a bit longer than the average for most infants, but this is not a relevant finding that causes complications soon after birth. The nurse does not need to see the infant first.
Choice D is incorrect. The risk of neonatal hypoglycemia is highest in first few hours after birth in some “at-risk” infants. These “at risk” infants include those who are post-term infants ( at or beyond 42 weeks gestation), late preterm (34-36.6 weeks gestation), term infants who are small for gestational age, infants of diabetic mothers, and large for gestational age infants. An infant born at 40 weeks ( Choice D) is referred to as a term infant, and there are no reported problems from the previous shift. No risk factors have been mentioned. The American Academy of Pediatrics (AAP) guidelines do not recommend routine screening and monitoring of blood glucose in healthy term infants after a normal pregnancy and delivery. The nurse does not need to assess this newborn first.
Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family; Lippincott, Williams & Wilkins
A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure?
A. High forceps delivery
B. Oxytocin induction
C. Amnioinfusion
D. Cesarean birth
Explanation
Correct Answer is C. The fetus is experiencing variable decelerations of heart rate in the setting of ruptured membranes. Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can help cushion the cord and relieve pressure when the membranes have ruptured.
Choice Ais is incorrect. A high forceps delivery is contraindicated because it is associated with fetal and maternal tissue damage. The situation does not meet the criteria to resolve to forceps deliveries. Per ACOG, appropriate forceps deliveries are indicated as in 1. Outlet forceps ( when presenting part on the perineum, the scalp visible at the vaginal opening) 2.Low Forceps ( when the leaning edge of the fetal skull is at station 3) Mid Forceps ( when the leaning side of the fetal head is between 0 and 2 stations).
Choice B is incorrect. The fetal heart rate findings in this case of ruptured membranes describe variable decelerations caused by cord compression. Oxytocin infusion could increase the pressure on the umbilical cord. It is also not recommended when labor is progressing adequately.
Choice D is incorrect. Even when there is cord compression, the situation states that compression is relieved, as indicated by the quick return of the heart rate to baseline. If the benchmark is reassuring, there is no need for immediate delivery or cesarean delivery.
A client is about to go for a CT angiogram, which involves the administration of an intravenous radiopaque dye. In preparing the client for the procedure, the nurse’s responsibility is to educate him by saying:
A. “You should expect some chest tightness during the procedure.”
B. “ You should expect a burning sensation at the intravenous site.”
C. “You will likely experience flushing of the face.”
D. “An allergic reaction may cause a decline in your kidney function.”
Explanation
Choice C is correct. Flushing of the face is an expected response to the intravenous administration of contrast dye. Many diagnostic and imaging procedures (CT scans, angiograms, myelograms) involve the use of Intravenous radiocontrast (intravenous dye, iodinated contrast). These contrast dyes contain iodine. Most patients experience a warm sensation throughout the body shortly after contrast dye infusion. This is more pronounced in the face and throat and thereafter, moves to the pelvic area.
Allergic reactions to intravenous contrast are seen only in about 5% to 8% of patients. Such reactions, therefore, are not expected responses.
The contrast media acts directly to release histamine and other mediators from mast cells. There is no allergic antibody mediating this reaction. Hence, it is referred to as “pseudo-allergy.”
Choice A is incorrect. Chest tightness may be experienced during a moderate to a severe hypersensitivity reaction and is not an expected response.
Choice B is incorrect. Burning at the intravenous site is not a usual expected response with the use of IV contrast dye.
Choice D is incorrect. Iodinated contrast is also toxic to the kidneys. This is not an allergy and is a direct toxic effect. It is important that the serum creatinine of the clients receiving iodinated contrast be checked before the procedure. If the estimated glomerular filtration rate (GFR) is less than 30ml/min, contrast dye must not be given. For those at-risk of renal toxicity, intravenous hydration must be given following contrast containing procedures.
Upon gathering the lab results from your prenatal client’s recent blood draw. the nurse notes that the patient’s red blood cell levels have decreased since before pregnancy. The nurse believes that physiological anemia is likely occurring. a result from a/an:
A. Decrease in circulating red blood cells
B. Increase in plasma
C. Increase in iron demands from the body
D. Decrease in heart size
Explanation
Choice B is correct. Physiological anemia occurs when there is an increase in plasma in the blood, thus “outweighing” the number of otherwise normal red blood cell levels. Physiological anemia is normocytic ( normal red cell size), whereas anemia caused by iron deficiency would be “microcytic.”
Choice A, C, and D are incorrect. In physiological anemia, there is no decrease in the circulating red blood cells; instead, there is an increase in plasma volume, causing dilutional anemia. While pregnancy does call for increased iron demands, this does not lead to physiological anemia; instead, iron deficiency leads to pathological microcytic anemia. Finally, pregnancy causes an increase in heart size, not a decrease.
NCSBN client need |Topic: Health Promotion and Maintenance: Intrapartum care
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.
