Nokea
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
- A. A large gush of clear fluid from the vagina
- B. Systolic hypertension
- C. Abdominal rigidity
- D. Increased fetal movements
Correct Answer: C
Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.
You may also like to solve these questions
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?
- A. Assure her that this is most likely the result of bladder spasms.
- B. Check the collection bag and tubing to verify that the catheter is draining properly.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Ask her if she has felt this way before.
Correct Answer: B
Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.
A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250 mg per mL. How many mL should the nurse administer?
Correct Answer: 0.8
Rationale: Dose: 200 mg ÷ 250 mg/mL = 0.8 mL. The nurse should administer 0.8 mL.
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Encourage exercises in the unaffected extremities.
- B. Encourage her to cross and uncross her legs.
- C. Check neurological and circulatory status of the affected leg hourly.
- D. Place a trochanter roll along the upper thigh of the affected leg.
Correct Answer: B
Rationale: Exercising the unaffected extremities will prevent contractures and emboli. Crossing and uncrossing the affected leg after surgery can dislocate the joint. Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
- A. Notifying the physician
- B. Changing the client to the left lateral position
- C. Continuing to monitor the FHR closely
- D. Administering O2 at 8 L/min via face mask
Correct Answer: C
Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.