Nokea
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
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Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
Which of the following actions should the nurse include in the plan?
- A. Maintain eye contact with the newborn during feedings
- B. Minimize noise in the newborn's environment.
- C. Swaddle the newborn with his legs extended
- D. Administer naloxone to the newborn.
Correct Answer: B
Rationale: Minimizing noise and stimuli helps to reduce symptoms of neonatal abstinence syndrome.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
Which of the following actions should the nurse take?
- A. Monitor for the development of Koplik spots.
- B. Isolate the client from staff who are pregnant.
- C. Administer aspirin to the client
- D. Initiate airborne precautions
Correct Answer: B
Rationale: Pregnant women should avoid contact with individuals who have rubella due to the risk of congenital defects.