Nokea
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
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Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.