Nokea
The nurse is assessing fetal presentation in a multiparous client. The fi gure below indicates which of the following types of presentations?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: C
Rationale: Although breech presentations are rare, footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the pelvis. In frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the sides of the fetal head. In complete breech, there is fl exion of the fetal thighs and knees; the fetus appears to be squatting. Vertex position occurs in 95% of deliveries; in such cases, the head is engaged in the pelvis.
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The nurse is preparing a presentation on nutrition to a group of pregnant adolescents. Which of the following would be important for the nurse to include in the teaching plan?
- A. Spinach is an excellent source of calcium in the diet.
- B. Two to four servings of whole-grain products is recommended.
- C. Three or more servings of dairy products meet the calcium requirement.
- D. Vitamin A supplements may be necessary for clients who are vegetarian.
Correct Answer: C
Rationale: Three or more servings of dairy products provide adequate calcium, essential for fetal development and maternal bone health during pregnancy.
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
A client with a history of chronic kidney disease is prescribed sodium polystyrene sulfonate (Kayexalate). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding potassium in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate binds potassium in the gut, reducing serum potassium levels in chronic kidney disease.
Communicating with parents and children about health care has become increasingly significant because:
- A. Consumers of health care cannot keep up with rapid advances in science.
- B. The influence of the media and specialization have increased the complexity of managing health.
- C. Nurse educators have recognized the value of communication.
- D. Clients are more demanding that their rights be respected.
Correct Answer: B
Rationale: Media influence and medical specialization have increased healthcare complexity, making clear communication essential to ensure understanding and informed decision-making.
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.