Nokea
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
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The nurse has attended a staff education program about the signs of pregnancy. Which of the following is considered a positive sign of pregnancy?
- A. Amenorrhea
- B. Uterine soufflé
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: Fetal heartbeat is a positive sign of pregnancy, as it directly confirms the presence of a fetus.
The emergency department (ED) nurse cares for a child with epistaxis. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply ice or a cold cloth to the bridge of the nose if the bleeding persists.
- B. Apply continuous pressure to the tip of the nose with thumb and forefinger for at least 10 minutes.
- C. Provide the child with a drink to wash away the taste of blood.
- D. Have the child sit up with the neck forward or erect.
- E. Evaluate the bleeding to determine the effectiveness of the interventions.
Correct Answer: D, B, A, E, C
Rationale: Correct order: Sit upright, apply pressure, apply ice if needed, evaluate bleeding, provide a drink last.
The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.
A nurse is taking care of a client with acute peritonitis. The nurse should do which of the following to meet the client's nutritional needs?
- A. administer feedings via nasogastric (NG) tube
- B. administer gastric enteral feedings
- C. feed the client orally
- D. administer parenteral nutrition
Correct Answer: D
Rationale: Acute peritonitis often requires bowel rest due to inflammation, making oral or enteral feedings inappropriate. Parenteral nutrition is indicated to meet nutritional needs.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor?
- A. PT and PTT
- B. CBC
- C. BUN
- D. Liver enzymes
Correct Answer: D
Rationale: Isoniazid can cause hepatotoxicity, making liver enzyme monitoring critical.