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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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A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana slices. Toddlers at the age of 2 are developing their fine motor skills and independence. Banana slices are easy for toddlers to pick up and eat independently, promoting their self-feeding skills. Grapes pose a choking hazard due to their size and shape. Hot dogs are also a choking hazard as they can easily get stuck in a toddler's throat. Popcorn is a common choking hazard for young children due to its hard texture. Therefore, recommending banana slices will not only promote independence in eating but also ensure safety for the toddler.
Which of the following findings require follow-up?
- A. 30-year-old client at 33 weeks gestation, Gravida 4 Para 3
- B. CBC and urinalysis collected and sent to lab.
- C. Maternal blood type: Rh+
- D. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- E. Client reports lower back pain and pinkish vaginal discharge.
- F. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds,
- G. FHR baseline 145, minimal variability.
Correct Answer: E,F,G
Rationale: The correct answers are E, F, and G because they indicate potential complications during pregnancy.
E: Lower back pain and pinkish vaginal discharge can be signs of preterm labor or placental issues, requiring immediate follow-up.
F: Uterine contractions every 8 minutes, strong palpation, and duration 30 seconds suggest active labor, needing monitoring for progression.
G: Fetal heart rate (FHR) baseline of 145 with minimal variability may indicate fetal distress, necessitating further assessment.
Other choices are routine findings or do not pose immediate risks, such as A (normal obstetric history), B (routine lab tests), C (Rh+ blood type is common), and D (history of preterm birth but no current concerns).
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.
- A. Change the indwelling urinary catheter tubing every 3 days
- B. Empty the drainage bag when it is half-full
- C. Place the drainage bag on the bed when transporting the client.
- D. Use soap and water to provide perineal care
- E. Review the need for the indwelling urinary catheter daily.
- F. Encourage the client to drink 3000 mL of fluid daily
Correct Answer: D,E
Rationale: Proper hygiene and regular assessment of catheter necessity reduce UTI risks.
Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy?
- C. The hepatitis& immunization should not be obtained until after you finish breastfeeding
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The correct answer is D: You can receive the immunization for influenza at any time during your pregnancy. This statement is correct because the influenza vaccine is recommended for pregnant women at any stage of pregnancy to protect both the mother and the unborn baby. It is safe and effective during pregnancy.
Incorrect choices:
A: The immunization for varicella should be given at least 1 month prior to delivery - This is incorrect because the varicella vaccine is not routinely recommended during pregnancy.
B: You can receive the rubella immunization during the third trimester of pregnancy - This is incorrect because the rubella vaccine is contraindicated during pregnancy.
C: The hepatitis B immunization should not be obtained until after you finish breastfeeding - This is incorrect because the hepatitis B vaccine is recommended during pregnancy to prevent transmission to the baby.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.