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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The nurse should first anticipate-------, followed by-----------
- A. obtain IV access
- B. place the client o a supine position with feet elevated
- C. recheck the diene's oxygen saturation
- D. Call the surgical suite to notify that the client is arriving STAT
- E. prepare to administer TV fluids
- F. check an arterial blood gas
- G. check an ECG
Correct Answer: A,E
Rationale: The correct answer is A, obtain IV access, and E, prepare to administer IV fluids. First, obtaining IV access is essential to establish a route for administering medications and fluids. This step is crucial in a critical situation to ensure quick access for emergency interventions. Next, preparing to administer IV fluids is important to address potential fluid imbalances or hypovolemia in the client. The other choices are incorrect because placing the client in a supine position with feet elevated (B) may be contraindicated in certain conditions, rechecking oxygen saturation (C) may delay urgent interventions, calling the surgical suite (D) is premature without stabilizing the client first, checking an arterial blood gas (F) and ECG (G) are important but not immediate priorities in this scenario.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not use my affected hand for 4 to 6 weeks.
- B. I will need to keep my hand elevated above my heart for several days.
- C. I should expect numbness and tingling in my hand.
- D. I can apply heat for the first 24 hours to minimize the pain in my hand.
Correct Answer: B
Rationale: Elevation reduces swelling postoperatively.
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is crucial as it assesses the client's capability and involvement in the process, promoting independence and preventing complications. Choice B is incorrect as assistive devices may be necessary for safety. Choice C is incorrect as raising side rails can limit access and may not be needed. Choice D is incorrect as discussing preferences is important but not directly related to repositioning.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalga
- C. Renal calculi
- D. Fibrocystic breast disease
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. Hypertension can be exacerbated by hormonal contraceptives, leading to serious complications like stroke or heart attack. It is crucial for women with hypertension to avoid estrogen-containing contraceptives.
B: Fibromyalgia, C: Renal calculi, D: Fibrocystic breast disease are not contraindications to combination oral contraceptive use. Fibromyalgia is a chronic pain disorder, renal calculi are kidney stones, and fibrocystic breast disease is a benign breast condition. These conditions do not impact the safety or efficacy of hormonal contraceptives.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.
- A. Place client in supine position
- B. Limit fluid intake to 3,000 mL/day
- C. Administer oxytocin
- D. Maintain bed rest with bathroom privileges
- E. Administer betamethasone.
- F. Administer terbutaline.
Correct Answer: D,E,F
Rationale: [0, 0, 0, 1, 1, 1]
For the correct answer :
- D: Maintaining bed rest with bathroom privileges is anticipated as it helps in preventing physical strain while allowing essential movement.
- E: Administering betamethasone is anticipated for fetal lung maturation in preterm labor.
- F: Administering terbutaline is anticipated for delaying preterm labor by relaxing uterine muscles.
Other choices:
- A: Placing the client in a supine position is not anticipated as it can decrease blood flow to the fetus.
- B: Limiting fluid intake to 3,000 mL/day is not anticipated as hydration is vital during pregnancy.
- C: Administering oxytocin is not anticipated unless there is a specific indication for labor induction.