Nokea
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-oid, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color.” Client also reports contractions began about 4 hr ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
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A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities.
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by
anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min
with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. self-centered behavior
- D. violates others rights
Correct Answer: C
Rationale: The correct answer is C: self-centered behavior. Individuals with historic personality disorder often display self-centered behavior as they prioritize their own needs and desires above others. This is due to their excessive need for admiration and attention. The other options are incorrect because: A: Suspicious of others is more characteristic of paranoid personality disorder. B: Callousness is more indicative of antisocial personality disorder. D: Violates others' rights is a feature of antisocial personality disorder as well.
A nurse is caring for a 9-year-old child at a clinic.
Vital Signs
1000:
Temperature 36.8° C (98.2° F)
Heart rate 102/min|
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Nurse determines that the assessment findings are consistent with which of the following conditions?Click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation.
- A. Edema
- B. Ecchymosis
- C. Pain level
- D. Sensation
Correct Answer: A,B,C,D
Rationale: Edema, ecchymosis, pain, and altered sensation are common in sprains, fractures, and dislocations.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.
Provider Prescriptions
1030:
Obtain x-rays of right arm, wrist, and elbow.
Drag words from the choices below to fill in each blank.Nurse should anticipate a prescription for--------and-------
- A. skin traction
- B. surgical consultation
- C. pain medication
- D. limb immobilization
- E. antibiotics
- F. bed rest
Correct Answer: C,D
Rationale: Pain medication and limb immobilization are standard for managing fractures, reducing discomfort and promoting healing.