safety

"My lips and fingers are tingling."

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action?

Obtain an order for catheterization to protect the bladder from trauma.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Use the large muscles of the leg when lifting items.

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include?

At ovulation, a mature follicle ruptures, releasing an ovum.

A nurse is providing information regarding ovulation to a couple who want to have a baby. Which fact should the nurse tell the clients?

The side rails on the head and foot of the bed are in the up position.

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?

Fetal movement felt by examiner

A client arrives to the clinic very excited and reporting a postive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?

Apply a sunscreen before exposure to the sun.

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol, 10 mg by mouth twice per day. During a discharge teaching session, a nurse should provide which instruction to the client?

pain from the dilation or stretching of the cervix

A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?

Report a heart rate greater than 120 beats/minute to the health care provider.

A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Discontinue the blood transfusion at the beginning of the shift.

A client who had a hip placement at 0900 is receiving an autologous blood transfusion that was started at 1100. At the change of shift (1500), the nurse working on the day shift reports that there is 50 mL of the unit of blood remaining to be infused. Which is a priority nursing action for the nurse working on the evening shift?

mifepristone

A nurse is providing care to a client with uterine fibroids who is prescribed a progestin antagonist. Which medication would the nurse most likely expect the client to receive?

Have client take deep breaths.

When administering IV midazolam hydrochloride to a client, what should the nurse do?

serum creatinine

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value?

Compound

Which type of fracture is one in which the skin or mucous membrane extends to the fractured bone?

neuroleptic malignant syndrome

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect?

Request information about nursing responsibilities in caring for a client with a pump.

A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?