Nokea
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
You may also like to solve these questions
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long term treatment will prevent future seizures.
Correct Answer: B
Rationale: The seizure may or may not mean your child has epilepsy. A single seizure has multiple potential causes, not necessarily epilepsy.
A male client is admitted for evaluation of a sudden hearing loss. No physical cause can be found for his sudden deafness; however, a friend reveals that the client's fiancée recently canceled their engagement, saying that she needed more time to think about the marriage. The client's deafness is an example of:
- A. Conversion reaction
- B. Hypochondriasis
- C. Reaction formation
- D. Histrionic personality disorder
Correct Answer: A
Rationale: Sudden deafness after emotional stress, without physical cause, indicates a conversion reaction, where psychological distress manifests physically.
Which of these statements best describes the characteristic of an effective reward-feedback system?
- A. Specific feedback is given as close to the event as possible
- B. Staff are given feedback in equal amounts over time
- C. Positive statements precede a negative statement
- D. Performance goals should be higher than what is attainable
Correct Answer: A
Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.