Nokea
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
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The nurse has a client with knee surgery who is receiving patient-controlled analgesia (PCA) of meperidine (Demerol). Which assessment finding would be a priority due to the use of this device and medication?
- A. Pulse rate 108
- B. $100 \mathrm{cc}$ of green emesis
- C. Respiratory rate of 10
- D. Lack of pain relief
Correct Answer: C
Rationale: The patient is in danger of respiratory depression due to narcotic administration; therefore, this would be a priority assessment. Answer A does not relate to the PCA, so it is incorrect. Answer B is not a priority, making it wrong. Pain relief in answer D is important, but not as important as airway, so it is incorrect.
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- A. the muscles
- B. the cerebellum
- C. the kidneys
- D. the leg bones
Correct Answer: A
Rationale: the muscles. Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- 'myo' --which typically means muscle.
The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?
- A. I will need to lie on my stomach during the procedure.
- B. I should go to the bathroom to urinate before the procedure.
- C. I understand that a needle will be inserted between the bones in my lower spine during the procedure.
- D. I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.
Correct Answer: A
Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (A), requiring clarification. Urinating beforehand (B), needle insertion (C), and transient pain (D) are correct.
The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?
- A. Crackers and cheddar cheese
- B. Hard-boiled egg with tomatoes
- C. Steamed fish and potatoes
- D. Tortilla chips with avocado dip
Correct Answer: C
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (A) to prevent hypertensive crisis. Fish and potatoes (C) are safe and nutritious. Eggs (B) and avocado (D) are safe but less balanced.