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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
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Which of the following actions should the nurse take?
- A. Monitor for the development of Koplik spots.
- B. Isolate the client from staff who are pregnant.
- C. Administer aspirin to the client
- D. Initiate airborne precautions
Correct Answer: B
Rationale: Pregnant women should avoid contact with individuals who have rubella due to the risk of congenital defects.
Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Use droplet precautions when caring for the child
- C. Assess the child for Koplik spots
- D. Administer aspirin to the child for fever.
Correct Answer: A
Rationale: Negative pressure rooms prevent airborne spread of varicella.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
Which of the following instructions should the nurse include?
- A. Perform chest percussion and postural drainage at least twice daily.
- B. Restrict intake of foods that contain gluten.
- C. Administer pancreatic enzymes on an empty stomach.
- D. Use a nebulizer to administer a bronchodilator fallowing airway clearance therapy.
Correct Answer: A
Rationale: The correct answer is A: Perform chest percussion and postural drainage at least twice daily. Chest percussion and postural drainage are essential airway clearance techniques for patients with cystic fibrosis to help mobilize and clear mucus from the lungs. Performing these techniques at least twice daily helps to prevent mucus buildup, reduce the risk of infections, and improve lung function. Restricting gluten intake (B) is not specific to cystic fibrosis management. Administering pancreatic enzymes on an empty stomach (C) is important for patients with cystic fibrosis to aid in digestion, but it is not directly related to chest physiotherapy. Using a nebulizer after airway clearance therapy (D) may be beneficial, but the primary focus should be on chest physiotherapy as the initial intervention for mucus clearance.
Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.