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The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
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The nurse is talking with a client who has a new prescription for metronidazole. Which of the following statements by the client would require follow up?
- A. I can continue to drink a glass of wine with dinner while I am taking this medication'
- B. I might experience a metallic taste in my mouth while I am taking this medication'
- C. I should not be concerned if my urine turns a dark color while taking this medication'
- D. I will immediately contact my health care provider if I experience a rash or skin peeling.'
Correct Answer: A
Rationale: Drinking alcohol while taking metronidazole can cause a disulfiram-like reaction, requiring follow-up. Metallic taste and dark urine are common side effects, and reporting rash or peeling is appropriate.
A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to
- A. add dietary fiber
- B. reduce ammonia levels
- C. stimulate peristalsis
- D. control portal hypertension
Correct Answer: B
Rationale: Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.
An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?
- A. Ask the physician for an order for a sleeping medication.
- B. Encourage the client to do mild exercises a half hour before going to bed.
- C. Suggest to the client that she not nap during the day.
- D. Recommend the client drink coffee in the evening.
Correct Answer: C
Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.
The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?
- A. The nursing assistant places an abductor pillow between the client's legs while turning the client.
- B. The nursing assistant asks the client to put full weight on both legs while using the walker.
- C. The nursing assistant has a high extended bedside commode available for the client.
- D. The nursing assistant encourages the client to bathe herself.
Correct Answer: B
Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.
A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?
- A. I will launder recently worn clothing, sheets, and towels in hot water.'
- B. I will make sure all eating utensils are placed in the dishwasher.'
- C. I will spray the house with insecticide to control this problem.'
- D. I will throw away stuffed animals and toys that cannot be washed.'
Correct Answer: A
Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.