Nokea
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her doctor
- B. Start an IV
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client (e.g. to the left side) can relieve pressure on the cord and improve fetal oxygenation. Notifying the doctor or starting an IV are secondary if repositioning resolves the issue.
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The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Ventricular arrhythmias
- D. Loss of peripheral pulses
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.
The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?
- A. Blood pressure of 150/100
- B. 2+ proteinuria
- C. Absence of deep tendon reflexes
- D. Edema of the lower extremities
Correct Answer: C
Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Reduces the possibility of air embolism
- C. Reduces the possibility of hematoma formation
- D. Makes the procedure more comfortable for the client
Correct Answer: B
Rationale: The Trendelenburg position reduces air embolism risk by increasing central venous pressure and distending veins for easier catheter insertion.