Nokea
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
You may also like to solve these questions
A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:
- A. Deep tendon reflexes
- B. Blood pressure
- C. Urine output
- D. Tissue turgor
Correct Answer: B
Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
- A. Mechanical ventilation
- B. Nebulizer treatments
- C. Chest physiotherapy
- D. Antibiotic therapy
Correct Answer: A
Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.
The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:
- A. Position the client on the strong side
- B. Encourage passive range of motion
- C. Provide a high-protein diet
- D. Use a sling for the affected arm
Correct Answer: D
Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to:
- A. Place the examining table in the Trendelenburg position
- B. Assess the client to see if she is having vaginal bleeding
- C. Obtain the client's vital signs immediately
- D. Help the client to a sitting position
Correct Answer: D
Rationale: This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. This would not be the first intervention the RN should initiate. The RN should understand the supine position and its effect on the gravid uterus and vena cava. The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
- A. Eating three large meals a day
- B. Drinking small amounts of liquids with meals
- C. Taking a long walk after meals
- D. Eating a low-carbohydrate diet
Correct Answer: D
Rationale: A low-carbohydrate diet prevents a hypertonic bolus, reducing dumping syndrome. The other options exacerbate the condition.