Nokea
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station +2 means that the:
- A. Presenting part is 2 cm above the level of the ischial spines
- B. Biparietal diameter is at the level of the ischial spines
- C. Presenting part is 2 cm below the level of the ischial spines
- D. Biparietal diameter is 5 cm above the ischial spines
Correct Answer: C
Rationale: Station +2 means the presenting part is 2 cm below the ischial spines, indicating descent in the pelvis.
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The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain?
- A. Norco (hydrocodone/APAP)
- B. Erythrocin (erythromycin)
- C. Zyrtec (cetirizine)
- D. Aldactone (spironolactone)
Correct Answer: B
Rationale: Erythromycin commonly causes gastrointestinal side effects, including abdominal pain, due to its motility-stimulating effects. Norco may cause constipation, Zyrtec is less likely to affect the GI tract, and Aldactone’s side effects are primarily electrolyte-related.
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
- A. Notify physician of nonreassuring FHR pattern.
- B. Turn the client to her left side.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Evaluate to see if the monitor strip is reassuring.
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
The nurse is teaching a client with a history of chronic kidney disease about dietary modifications. The nurse should tell the client to:
- A. Limit phosphorus intake
- B. Increase sodium intake
- C. Consume high-potassium foods
- D. Increase protein intake
Correct Answer: A
Rationale: Limiting phosphorus intake prevents bone and cardiovascular complications in chronic kidney disease.
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Always allow the most vocal person to state the problem first.
- B. Encourage the mother to speak for the children.
- C. Interpret immediately what seems to be going on within the family.
- D. Allow family members to assume the seats as they choose.
Correct Answer: D
Rationale: Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.