Nokea
As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus' presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus' presenting part to the anterior, posterior, right or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus' presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct Answer: D
Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.
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A client with a history of Addison's disease is prescribed hydrocortisone. The nurse should instruct the client to report which of the following side effects immediately?
- A. Weight gain.
- B. Hypoglycemia.
- C. Mood changes.
- D. Muscle weakness.
Correct Answer: C
Rationale: Mood changes may indicate corticosteroid excess, requiring immediate reporting to adjust the hydrocortisone dose.
The nurse is caring for a client post-total knee replacement. Which sign indicates a potential deep vein thrombosis?
- A. Calf swelling and pain
- B. Fever of 100°F (37.8°C)
- C. Mild incisional redness
- D. Joint stiffness
Correct Answer: A
Rationale: Calf swelling and pain are classic signs of deep vein thrombosis, a common postoperative complication requiring immediate evaluation.
You are the Assistant Director of Nursing in a multi ethnic and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing multi ethnicity and the culturally diverse nature of this facility for this philosophy?
- A. Jean Watson's
- B. Martha Rogers'
- C. Nagi's theory
- D. Madeleine Leininger's theory
Correct Answer: D
Rationale: Madeleine Leininger's theory of Transcultural Nursing focuses on providing culturally congruent care, making it the most appropriate framework for addressing the needs of a multi-ethnic and culturally diverse population.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
- A. 15 to 30 minutes
- B. 1 to 2 hours
- C. 2 to 4 hours
- D. 4 to 6 hours
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
- A. Pallor
- B. Hypertension
- C. A low hematocrit level
- D. Pale mucous membranes
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.