Nokea
A 23-year-old woman in active labor.
The nurse observes the fetal heart monitor for a 23-year-old woman in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is
- A. a slowing early in the contraction, and is usually a normal finding.
- B. a slowing early in the contraction, and is usually an abnormal finding.
- C. a slowing at the peak of the contraction, and is usually a normal finding.
- D. a slowing at the peak of the contraction, and is usually an abnormal finding.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-occurs in response to compression of fetal head, uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress (2) does not indicate fetal distress (3) slowing is early in the contraction (4) slowing is early in uterine contraction and is not abnormal
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Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
Procrastination, noncompliance, and intentional inefficiency are characteristics of the client with:
- A. Avoidant personality disorder
- B. Antisocial personality disorder
- C. Compulsive personality disorder
- D. Passive aggressive personality disorder
Correct Answer: D
Rationale: Passive aggressive personality disorder is characterized by indirect resistance, such as procrastination and intentional inefficiency.
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
- A. I'm going to try feeding my baby some rice cereal.'
- B. When he wakes at night for a bottle, I feed him.'
- C. I dip his pacifier in honey so he'll take it.'
- D. I keep formula in the refrigerator for 24 hours.'
Correct Answer: C
Rationale: I dip his pacifier in honey so he'll take it.' Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
The nurse is caring for a client with a history of type 2 diabetes who is receiving insulin aspart (NovoLog) 10 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 80 mg/dL.
- B. Heart rate of 90 bpm.
- C. Sweating and shakiness.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Sweating and shakiness indicate hypoglycemia, a serious complication of insulin aspart, requiring immediate treatment with carbohydrates. Options A, B, and D are less concerning: glucose 80 mg/dL is normal, heart rate 90 bpm and blood pressure 130/80 mmHg are stable.