Nokea
The client is having fetal heart rates of 100-110 beats per minute during the contractions. The first action the nurse should take is to:
- A. Apply an internal monitor
- B. Turn the client to her side
- C. Get the client up and walk her in the hall
- D. Move the client to the delivery room
Correct Answer: B
Rationale: Turning the client to her side improves uteroplacental perfusion, addressing fetal bradycardia during contractions.
You may also like to solve these questions
The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has:
- A. Aplastic anemia
- B. Iron-deficiency anemia
- C. Pernicious anemia
- D. Hemolytic anemia
Correct Answer: B
Rationale: Hypochromic, microcytic red blood cells are characteristic of iron-deficiency anemia, caused by insufficient iron for hemoglobin synthesis.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
A client is admitted to the surgical unit following a transurethral prostatectomy (TURP). The nurse administers a B&O suppository to help prevent bladder spasms. The nurse would observe the client for:
- A. Insomnia and hyperactivity
- B. Physiological dependence on the drug
- C. Nausea and vomiting
- D. Diarrhea and abdominal cramping
Correct Answer: C
Rationale: Belladonna and opium (B&O) suppositories can cause nausea and vomiting as side effects. These are more immediate concerns than dependence or the other symptoms.
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
- A. Cyanocobalamine
- B. Protamine sulfate
- C. Streptokinase
- D. Sodium warfarin
Correct Answer: B
Rationale: Protamine sulfate neutralizes heparin's anticoagulant effect.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.