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In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
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The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
- A. Capillary refill less than 3 seconds
- B. Pale mucous membranes
- C. Respirations 20 breaths per minute
- D. Complaints of fatigue when ambulating
Correct Answer: A
Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.
The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:
- A. $48-72$ hours
- B. 5-7 days
- C. 2-4 weeks
- D. 3-6 months
Correct Answer: C
Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect. Choices A and B are too short, and D is excessively long.
The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.
- A. Consult the health care provider (HCP) if you experience leg pain or swelling
- B. Discontinue contraceptives if you experience spotting between menses
- C. Do not smoke while taking combined contraceptives
- D. Immediately report any breast tenderness to the HCP
- E. Seek immediate medical treatment if you experience vision loss
Correct Answer: A,C,E
Rationale: For combined oral contraceptives: report leg pain/swelling for possible DVT; avoid smoking due to increased cardiovascular risk; and seek treatment for vision loss indicating possible stroke. Spotting is common and breast tenderness is not urgent.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.