Nokea
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses’ Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data.
Drag a word from the choices below to complete the sentence.
Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
- A. first
- B. second
- C. third
- D. fourth
- E. latent
- F. active
- G. transition
Correct Answer: A, F
Rationale: Cervical dilation of 6 cm with 100% effacement and frequent contractions indicate the first stage of labor, active phase.
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The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
- A. a low sodium diet
- B. a mechanical soft diet
- C. a renal diet
- D. a high-fiber diet
Correct Answer: B
Rationale: A mechanical soft diet is appropriate for an edentulous client to ensure safe chewing and swallowing.
The nurse is performing a physical assessment on a newborn. The nurse assessed 3+ brachial pulses, cold and pale feet, decreased capillary refill time in the feet, and warm and pink hands. Which cardiac disease process do these assessment findings support?
- A. Tetralogy of Fallot (TOF)
- B. Hypoplastic left heart syndrome
- C. Coarctation of the aorta (COA)
- D. Transposition of the great arteries
Correct Answer: C
Rationale: These findings suggest coarctation of the aorta, with reduced lower extremity perfusion due to aortic narrowing.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 2 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The nurse considers if the client may have an infection caused by a tick. Click to specify if the features are consistent with the disease process of Rocky Mountain spotted fever (RMSF) or Lyme Disease.
- A. Fever
- B. Petechial rash that becomes diffuse
- C. Erythema migrans (bullseye rash)
- D. Myalgia
- E. Causative agent Rickettsia rickettsii
- F. Causative agent Borrelia burgdorferi
Correct Answer: C (Lyme Disease), F (Lyme Disease)
Rationale: The bullseye rash and Borrelia burgdorferi are specific to Lyme disease. Fever and myalgia can occur in both RMSF and Lyme disease, but the petechial rash and Rickettsia rickettsii are specific to RMSF.
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
- A. Oral diphenhydramine
- B. Nebulized albuterol
- C. Oral prednisone
- D. Parenteral epinephrine
Correct Answer: D
Rationale: Anaphylaxis from a bee sting requires immediate parenteral epinephrine to reverse airway edema and respiratory distress.