Nokea
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
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The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
A newborn.
While performing a physical examination on a newborn, which of the following nursing assessments should be reported to the doctor?
- A. Head circumference of 40 cm.
- B. Chest circumference of 32 cm.
- C. Acrocyanosis and edema of the scalp.
- D. Heart rate 160 and respirations 40.
Correct Answer: A
Rationale: Strategy: Determine if the assessment is abnormal. (1) correct-average circumference of the head for a neonate ranges from 32 to 36 cm; increase in size may indicate hydrocephaly or increased intracranial pressure (2) normal newborn assessment (3) normal newborn assessment (4) normal newborn assessment
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
A nurse receives a report on a client 3 days postoperative abdominal surgery that includes four saturated dressing changes in 8 hours. On assessment of this client, dehiscence and evisceration of the wound are noted. After applying a sterile, moistened 4-x-4, what is the nurse's next action?
- A. Place the client in the dorsal recumbent position.
- B. Notify the RN in charge.
- C. Wrap an Ace bandage around the abdomen.
- D. Use a wheelchair to transport the client to the treatment room.
Correct Answer: B
Rationale: After the saline dressing is applied, the RN should be notified—probable repair is necessary. Answer A is wrong because low Fowler's position should be used. Answer C will not help, so it's incorrect. Answer D is inappropriate at this time, so it's incorrect.