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A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?
- A. Monitor the fetal heart rate.
- B. Notify the primary health care provider.
- C. Transfer the client to the delivery room.
- D. Place the client in the Trendelenburg position.
Correct Answer: D
Rationale: On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client in the Trendelenburg position while gently holding the presenting part upward to relieve the cord compression. This position is maintained and the primary health care provider is notified. The fetal heart rate also needs to be monitored to assess for fetal distress. The client is transferred to the delivery room when prescribed by the primary health care provider.
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The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.
A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?
- A. Ensure that the client is appropriately dressed.
- B. Administer an opioid analgesic 30 to 60 minutes before therapy.
- C. Schedule the therapy at a time when the client generally takes a nap.
- D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B
Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.
A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure?
- A. Mole skin-lined heel protectors
- B. Regular use of posterior splints
- C. Application of pneumatic boots
- D. Avoiding dorsal flexion of the foot
Correct Answer: B
Rationale: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.