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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. Contractions lasting 80 seconds.
- B. FHR baseline 170/min.
- C. Early decelerations in the FHR.
- D. Temperature 37.4°C (99.3°F).
Correct Answer: B
Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.
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A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.
A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct Answer: A
Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.
A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct Answer: C
Rationale: The correct answer is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Auscultate the newborn's apical pulse for 60 seconds
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence
Correct Answer: C
Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.
The healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
- A. Hyperthyroidism
- B. Thrombophlebitis
- C. Diverticulosis
- D. Hypocalcemia
Correct Answer: B
Rationale: Thrombophlebitis is a condition characterized by inflammation of a vein, which increases the risk of blood clots. The use of oral contraceptives further elevates the risk of clot formation, making them contraindicated in individuals with thrombophlebitis. Hyperthyroidism (Choice A), diverticulosis (Choice C), and hypocalcemia (Choice D) are not contraindications to the use of oral contraceptives.