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In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
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The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to
- A. Avoid caffeine
- B. Keep feet dry
- C. Reduce stress
- D. Wear gloves
Correct Answer: A
Rationale: Avoid caffeine. Caffeine can trigger vasoconstriction, exacerbating Raynaud's phenomenon symptoms, making it a priority after smoking cessation.
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.
The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers?
- A. Demonstrating adequate coping skills
- B. Knowing how to keep blood sugars stable
- C. Understanding how to perform meal planning
- D. Understanding the need for periodic follow-up visits
Correct Answer: B
Rationale: The priority outcome for caregivers of a child with type 1 diabetes is knowing how to keep blood sugars stable , as this directly impacts the child's health and prevents complications. Coping , meal planning , and follow-up are important but secondary.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.
The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?
- A. I can leave right after the shot as I didn't have a reaction last time.'
- B. I will be back in a week for my next allergy shot.'
- C. I will let the doctor know if I get any itchy hives tonight.'
- D. It is okay if I have some redness at the injection site tonight.'
Correct Answer: A
Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.