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A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify:
umbilical cord prolapse. Explanation: After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during cord compressions. Infection, the start of the second stage of labor, and the need for labor induction aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.
An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
Apply lanolin or petroleum jelly to intact skin. • Encourage a reduced-calorie, reduced-fat diet. • Inspect the involved areas daily for new ulcerations. • Use an electric razor to shave.
A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
Monitor the appearance, size, and number of stools. Explanation: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively.
A client is admitted for an arthroscopy of the right shoulder through same-day surgery. Which nurse is responsible for starting the client's discharge planning?
preadmission nurse Explanation: The preadmission nurse, the first person in contact with the client, starts the discharge planning for the client undergoing surgery. All nurses involved with the client, from preadmission through postoperative recovery, should continue to reinforce the discharge plan
pudendal block
used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair
A nurse is caring for a 34-month-old who is hospitalized for a lengthy illness. Which behaviors would the nurse identify as examples of expected developmental regression for the child's age group? Select all that apply.
• Enuresis. • Encopresis. • One to two word expressions
While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session?
-Safety guideline Reinforcing safety guidelines is appropriate because such anticipatory guidance helps prevent many accidental injuries
During a prenatal visit, a nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age?
19 weeks Explanation: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.
the ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following?
Contractility Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.
Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make
Evaluate the client for voluntary admission to a mental health facility. Explanation: A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care
An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery
Place the client in semi-Fowler's position with the knees to the chest. Explanation: Appendicitis typically begins with periumbilical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney point (located halfway between the umbilicus and the right iliac crest). To relieve pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated
A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make
Testicular cancer is a highly curable type of cancer. Explanation: Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger, not older, men
A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor?
cervical dilation and effacement Explanation: True labor is present when cervical dilation and effacement occur. Fetal descent into the pelvic inlet is an indication that labor will begin soon. However, for a nulligravid client, this may take 1 to 2 weeks. Painful contractions every 3 to 5 minutes may be Braxton Hicks contractions. Contractions that disappear when the client lies down are a sign of false labor. Although leaking amniotic fluid should be reported, it is not a sign of true labor.
Nägele's rule
the nurse calculates the client's EDD by adding 7 days to the first day of the last menstrual period (12 + 7 = 19) and subtracting 3 months from the month of the last menstrual period
What data indicates to the nurse that placental detachment is occurring?
An abrupt lengthening of the cord Explanation: An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus is not an indication for detachment of the placenta
When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal sysem
pulmonary Explanation: The shake test helps determine the maturity of the fetal pulmonary system. The test is based on the fact that surfactant foams when mixed with ethanol. The more stable the foam, the more mature the fetal pulmonary system. Although the shake test is inexpensive and provides rapid results, problems have been noted with its reliability. Therefore, the lecithin-sphingomyelin ratio is usually determined in conjunction with the shake test
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
some melanomas have a familial component and she should seek medical advice Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age-group. Severe sunburn as a child does increase the risk; however, this client is at increased risk because of her family history
Which medication is considered safe during pregnancy?
Insulin Explanation: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm
Assessment of a nulligravid client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; and fetal heart rate of 136 bpm. Which should the nurse plan to do next
Assist the client with comfort measures and breathing techniques. Explanation: The client's assessment findings indicate that the client is in the latent phase of the first stage of labor. Therefore, the nurse should plan to assist the client with comfort measures and breathing techniques to relieve discomfort. The client can move around, walk, or ambulate at this phase of labor. If the client chooses to remain in bed, a left side-lying position provides the greatest perfusion. It is too early for the client to have an epidural anesthetic. Epidural anesthesia is usually administered when the cervix is dilated 4 to 5 cm. The fetal heart rate is normal, so internal fetal monitoring is not warranted at this time
A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis should be the highest priority
Deficient fluid volume(hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage
A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to:
the social worker on call. Explanation: The social worker on call knows how to make a referral to authorities without violating the client's rights. The nurse does not need to contact the physician, because the physician would also refer the client to the social worker. The nurse does not have the right to refer the client to Women in Distress, an organization that shelters victims of abuse, without the client's permission. It is not appropriate for the nurse to refer the client to a lawyer.
Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?
Hypertonic Explanation: A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic
A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which of the following activities would the nurse be carrying out?
Reviewing health changes Explanation: During the termination phase of the nurse-client relationship, the nurse and the client review health changes and how the client has dealt with physical and emotional responses. During the orientation phase of the nurse-client relationship, the nurse and client work towards establishing trust and rapport. During the working phase of the nurse-client relationship, the nurse attends to the physical healthcare needs and develops solutions that are acted upon by the clien
A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which activity would be appropriate for the nurse to suggest?
swimming Explanation: Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball, and soccer usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function
After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate?
The movements occur from muscle reflexes that cannot be initiated or controlled by the brain." Explanation: The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.
The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?
increase in the fetal heart rate and variability Explanation: Fetal scalp stimulation is commonly prescribed when there is decreased fetal heart rate variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the fetal heart rate and variability. However, if the fetus is in distress and becoming acidotic, fetal heart rate acceleration will not occur. The fetal hematocrit level can be measured by fetal blood sampling. Scalp stimulation does not increase the strength of the contractions. However, it can increase fetal heart rate and variability. Fetal position is assessed by identifying skull landmarks (sutures) during a vaginal examination
After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?
hold her breath throughout the length of the contraction Explanation: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing. Semi-Fowler's position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired. The client should flex her thighs onto her abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter. The client should exert downward pressure as if she were having a bowel movement while pushing.
A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?
Assess the fetal heart rate. Explanation: Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium-stained fluid. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelerations), the health care provider (HCP) should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The HCP may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.
A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client?
in vitro fertilization (IVF) Explanation: Because this client's tubes are blocked, IVF would be the most appropriate. After ova are removed surgically from the client and fertilized outside the uterus, the fertilized ova are introduced vaginally through a special tube through the cervix to the uterus for implantation, completely bypassing the fallopian tubes. Gamete intrafallopian transfer, the transfer of ova into a patent fallopian tube for fertilization, would be inappropriate for client with blocked fallopian tubes. Zygote intrafallopian transfer involves oocyte retrieval then fertilization. After fertilization, the fertilized eggs are transferred into the client's fallopian tubes. This is not an option for a client who has blocked tubes. Menotropin therapy would be appropriate if the client was experiencing ovarian dysfunctio
A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
oxytocin 30 units in 500 ml D5W Explanation: A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place.
When planning a class for primigravid clients about the common physiologic changes of pregnancy, which information should the nurse include in the teaching plan?
Cardiac output increases by 25% to 50% during pregnancy. Explanation: During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fibrinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported, because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms.
A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for:
-starting oxygen The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant
What IV solutions would the nurse expect to be ordered for a patient who has hypovolemia? (Select all that apply.)
0.9% NaCl (normal saline) • Lactated Ringer's solution • 5% dextrose in 0.9% NaCl Explanation: 0.9% NaCl (normal saline) and Lactated Ringer's solution are isotonic solutions that have a total osmolality close to that of the ECF and help replace the ECF in the treatment of hypovolemia. 5% dextrose in 0.9% NaCl is a hypertonic solution that can temporarily be used to treat hypovolemia if plasma expander is not available. 10% dextrose in water (D10W) is a hypertonic solution that is used in peripheral parenteral nutrition. 0.45% NaCl (½-strength normal saline) is a hyptonic solution that provides Na+, Cl−, and free water and is used as a basic fluid for maintenance needs. 5% dextrose in water (D5W) is used in fluid loss, dehydration and hypernatremia, and should not be used in excessive volumes because it does not contain any sodium. (less)
After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which occurs?
A sudden gush of dark blood occurs. Explanation: A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and changing of the uterus to a round or spherical shape are impending signs of placental separation. Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion
The nurse determines that which of the following clients is at greatest risk for a wound infection?
A two-day postoperative client Explanation: The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection
A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. What should the nurse do upon the client's arrival?
Admit the client to a quiet, darkened room. Explanation: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour
A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress?
Blood pressure of 146/90 mm Hg Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus
A client has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next?
Check the client's potassium level. Explanation: The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the physician. Because the client is taking furosemide (Lasix), a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the physician with a more complete database. The physician will need to be notified after the nurse checks the latest potassium level. Calling the nurse-manager is not indicated at this time. Administering potassium requires a physician's orde
A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services. Explanation: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her spouse does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security
A nurse is caring for a patient who has a PICC line. Which nursing action is recommended
Flush using normal saline and/or heparin solution according to facility policy. Explanation: PICC lines are flushed with normal saline and/or heparin in order to maintain patency by preventing clot formation in the line. Sterile technique should be used for dressing changes for at least 24 hours after insertion and 3 to 7 days thereafter. The external part of the catheter should be kept under the dressing to prevent the introduction of microorganisms, leading to infection. Catheter caps should be changed every 3 to 7 days
A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?
Fundus two fingerbreadths above the umbilicus Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum.
Initial client assessment information includes: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?
Headache, blurred vision, and facial and extremity swelling Explanation: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most clients with preeclampsia have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia
A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?
Hypokalemia Explanation: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.
A primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?
Stop the magnesium sulfate infusion. Explanation: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.
A client who is in the end-stages of cancer is increasingly upset about receiving chemotherapy. Which approach by the nurse would likely be most helpful in gaining the client's cooperation?
Tell the client how the treatment can be expected to help. Explanation: The best course of action when the client has outbursts concerning treatments is to explain how the treatment is expected to help. Describing the effect if the client misses a treatment is a negative approach and may be threatening to the client. Explaining the effects of being upset does not deal with the client's feelings. Offering to arrange for a massage during the chemotherapy may be helpful, but does not deal with the client's immediate feelings
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
The cord lengthens outside the vagina. Correct Explanation: The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes more firm and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.
A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. The nurse should tell the woman:
The maximum blood loss considered within normal limits is 500 ml." Explanation: In a normal birth and for the first 24 hours postpartum, a total blood loss not exceeding 500 mL is considered normal. Blood loss during childbirth is almost always estimated because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage
A toddler is hospitalized for treatment of injuries that the staff believes were caused by child abuse. A staff member states that the parents "shouldn't be allowed to visit because they caused the child's injuries." When responding to this staff member, the nurse should base the comments on which understanding?
The parents should be encouraged to visit frequently and should be welcomed by the staff. Explanation: Abusive parents should be encouraged to visit their child frequently and should be welcomed by the staff. Many abusive parents love their children but lack effective parenting skills. The child's hospitalization offers an opportunity for the staff to demonstrate appropriate parenting behaviors to the parents
A dialysis nurse is teaching a patient to care for the dialysis access that was inserted in the patient's right arm. The nurse assesses the patient's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the patient's hospitalization. What phase of the working relationship is best described in this scenario?
The working phase Explanation: There are three phases of a helping relationship: the orientation phase, the working phase, and the termination phase. The introduction phase is not a valid phase, yet the nurse will introduce herself during the orientation phase. The scenario defines characteristics of the working phase, during which the nurse and patient work together to meet the patient's physical and psychosocial needs. During the orientation phase, the tone and guidelines for the relationship are established. The termination phase occurs when the conclusion of the initial agreement is acknowledged.
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should
Understand that his culture may influence his hygiene and ask him his preference Explanation: Preferences for hygiene vary widely among individuals and across cultures.
A client states the following to the nurse: "I am a failure, and I wish I had died." Which of the following statements by the nurse demonstrates a therapeutic response?
You feel like a failure; would you like to talk more about the way you feel?" Explanation: Acknowledging the client's feelings by repeating what the client states is therapeutic. It is also therapeutic for the nurse to offer to discuss the client's feelings further. The other options are incorrect because they dismiss the client's feelings.
Which client is at greatest risk for coronary artery disease?
a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) Explanation: The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to find:
a history of pelvic inflammatory disease. Explanation: Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated with grand multiparity or hormonal contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device for 2 years or more.
The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first:
assess the fetal heart rate (FHR) for 1 full minute. Explanation: After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the HCP. A cord prolapse requires prompt birth by cesarean section. The client's contraction pattern should be monitored once labor has been established. The client's temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is presen
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?
blue Explanation: If the client's membranes have ruptured, the nitrazine paper will turn blue, an alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other fluid forms this type of pattern
When preparing a 3-year-old child to have blood specimens drawn for laboratory testing, the nurse should:
use distraction techniques during the procedure. Explanation: A 3-year-old child responds best to distraction during a procedure because of the typical level of cognitive development of a 3-year-old and the fear of painful events. Preparation ... (more) Remediation: Blood culture sample collection, pediatric
A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care?
Assisting the client with bathing and dressing by giving clear, simple directions Explanation: This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required
A nurse is caring for a client who's in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?
Checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.
The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction?
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. Explanation: Induction of labor with an oxytocic agent carries risks, such as water intoxication and uterine rupture. Before beginning intravenous oxytocin infusion, the nurse should obtain a baseline measurement of fetal heart rate and assess the client's contractions. If the fetal heart rate pattern shows fetal distress, the client is not a candidate for induction. This monitoring continues throughout the duration of therapy. The infusion should be discontinued and the primary care provider notified if fetal distress is noted or if contractions occur less than 2 minutes apart or last longer than 60 seconds.
A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?
Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg Explanation: An increased heart rate (usually greater than 100 beats/minute, depending on the client's baseline) followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock
What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?
beginning of one contraction to the beginning of the next contraction Explanation: To assess the frequency of the client's contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction
The primigravid client is at +1 station and 9 cm dilated. Based on these data, the nurse should first:
encourage the client to breathe through the urge to push. Explanation: The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. Comfort measures are important for the client at this time but are not the highest priority for the nurse.
A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief?
hands and knees Explanation: Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP position. Tailor sitting facilitates descent in OA positions.
A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert fo
uterine atony. Explanation: A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after childbirth.
A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next?
Ask the client specifically about the possibility of physical abuse. Explanation:Many clients who experience abuse are hesitant to talk about it and need help to do so. The nurse should ask the client directly about abuse when it is suspected, using a sensitive, empathetic, and compassionate approach. In this way, the client can feel comfortable revealing information about the abuse. Telling the client that it is difficult to believe her injuries resulted from a fall is not helpful because it is blameful and puts the client on the defensive. Asking the client what she did to make someone hit her or discussing what she can do the next time blames and alienates the client
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings
Which of the following is a disadvantage to using the IV route of administration for analgesics?
Short duration Explanation: Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream
A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates teaching about spinal anesthesia has been understood?
"The anesthetic may cause a severe headache, which is treatable." Explanation: Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, or using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.
Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently?
Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease
A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise?
Allowing the client to ambulate as tolerated Explanation: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.
A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?
Ketones in urine. Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.
The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following?
Let's talk about this; do you want me to call a support person?" Explanation: The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Loss of consciousness Explanation: The earliest sign of increasing ICP is loss of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
