Nokea
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
- A. Notify the physician immediately.
- B. Perform a vaginal exam to assess dilation.
- C. Encourage the client to ambulate.
- D. Administer oxygen to the client.
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.
You may also like to solve these questions
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
- A. Her reasons for staying are complex. She can leave only when she is ready and can be safe.'
- B. I know it is frustrating to work with clients who don't follow our advice.'
- C. I need to do you have her again and have another chance.'
- D. These women almost never leave for good because of their emotional and financial dependency.'
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.
Select the client who is at greatest risk for the development of cancer.
- A. A 76 year old female client who has a history of alcohol abuse.
- B. A 76 year old female client who has a history of diabetes.
- C. A 64 year old male client who has a history of impaired oxygen transport.
- D. A 64 year old male client who has hypotension.
Correct Answer: A
Rationale: Alcohol abuse is a known risk factor for several cancers, including liver, esophageal, and breast cancer, due to chronic inflammation and carcinogenic effects of alcohol metabolites.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.