Nokea
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- A. Prepare the client for a caesarean section
- B. Apply the fetal heart monitor
- C. Place the client in the Trendelenburg position
- D. Perform an ultrasound exam
Correct Answer: B
Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.
You may also like to solve these questions
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
- A. The client can have a higher-calorie diet.
- B. The client has good control of her diabetes.
- C. The client requires adjustment in her insulin dose.
- D. The client has poor control of her diabetes.
Correct Answer: B
Rationale: A glycosylated hemoglobin (HbA1c) of 2.5% is below the normal range (4-5.6%), indicating overly tight glucose control, but in context, it suggests good diabetes management.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort can cause photosensitivity, increasing the risk of skin reactions, so sunscreen use is recommended, not avoided.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron and recommended for iron-deficiency anemia.
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order
- B. Try to obtain samples for the client to take home
- C. Perform discharge teaching regarding this drug
- D. Consult social services for financial assistance with obtaining the drug
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which can exacerbate ischemia. The nurse should question the prescription.
Which developmental milestone puts the 4-month-old infant at greatest risk for injury?
- A. Switching objects from one hand to another
- B. Crawling
- C. Standing
- D. Rolling over
Correct Answer: D
Rationale: Rolling over at 4 months increases the risk of falling from elevated surfaces like changing tables, a common cause of injury.