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The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?
- A. Assess cervical dilation.
- B. Change the client's position.
- C. Administer oxygen via facemask.
- D. Turn off the oxytocin infusion.
Correct Answer: B
Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.
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A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
- A. Drowsiness and bradycardia.
- B. Depressed reflexes and increased respirations.
- C. Tachycardia and a feeling of nervousness.
- D. A flushed, warm feeling and a dry mouth.
Correct Answer: C
Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant's growth chart
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How can a nurse make a blind 8-year-old girl admitted to the hospital more comfortable?
- A. Bring familiar toys from home, such as a bear or doll.
- B. Explain the surroundings to the child.
- C. Allow the child to explore the room.
- D. Provide audio books and music.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a child with HIV, which system should the nurse assess first?
- A. Assess the respiratory system.
- B. Assess the gastrointestinal system.
- C. Assess the cardiovascular system.
- D. Assess the neurological system.
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.