Nokea
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Fourth stage of labor
- B. Third stage of labor
- C. Transition stage of labor
- D. Second stage of labor
Correct Answer: C
Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.
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Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
- A. Persistent sadness
- B. Fever and chills
- C. Uterine tenderness
- D. Foul-smelling lochia
Correct Answer: A
Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.
The client is admitted at 32 weeks gestation with a diagnosis of gestational hypertension. Which assessment finding is most significant?
- A. Proteinuria of 2+
- B. Blood pressure of 140/90
- C. Edema of the hands and face
- D. Weight gain of 2 pounds per week
Correct Answer: A
Rationale: Proteinuria of 2+ is a significant finding in gestational hypertension as it suggests progression to preeclampsia which can lead to severe complications. BP of 140/90 edema and weight gain are concerning but less specific without proteinuria.
The nurse is caring for a client with a history of cirrhosis. Which dietary restriction is most important?
- A. Low fat
- B. Low protein
- C. Low sodium
- D. Low carbohydrate
Correct Answer: C
Rationale: Low sodium is critical in cirrhosis to reduce fluid retention and ascites caused by portal hypertension and hypoalbuminemia. Protein is moderated but not severely restricted, and fat and carbohydrates are less critical.
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
- A. Place a tongue blade in the child's mouth.
- B. Restrain the child so he will not injure himself.
- C. Go to the nurses station and call the physician.
- D. Move furniture out of the way and place a blanket under his head.
Correct Answer: D
Rationale: The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. Restraining the child's movements could cause constrictive injury. Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. The nurse should provide safety for the child by moving objects and protecting the head.