A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
- A. Support the infant as it emerges.
- B. Review prenatal laboratory results.
- C. Obtain fetal heart tones.
- D. Apply suprapubic pressure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse calculates that the woman's next fertile period is
- A. January 14-15.
- B. January 22-23.
- C. January 30-31.
- D. February 6-7.
Correct Answer: C
Rationale: To determine the fertile period, subtract 14 days from the length of the woman's menstrual cycle. In this case, 36-14 = 22. Counting forward from the first day of the last menstrual period (January 8), the fertile period falls around January 30-31. This is because ovulation typically occurs approximately 14 days before the start of the next menstrual period, marking the fertile window for conception.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?
- A. Check the hematocrit results.
- B. Administer pain medication.
- C. Increase the rate of IV fluids.
- D. Monitor the client for contractions.
Correct Answer: C
Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.
The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?
- A. Bilirubin of 1.5 mg/dl.
- B. Glucose of 80 mg/dl.
- C. Potassium of 4.5 mEq/L.
- D. Sodium of 119 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What should the nurse recommend to a woman with mastitis?
- A. Apply heat to the affected area.
- B. Apply cold compresses to the affected area.
- C. Use a breast pump to express milk.
- D. Continue breastfeeding as usual.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?
- A. Both partners have a daily exercise regimen that includes running four miles each morning.
- B. The couple has a history of having sexual intercourse 2 to 3 times per week.
- C. The woman's menstrual period occurs every 35 days.
- D. They use lubricants with each sexual encounter to decrease friction.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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