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Which assessment finding would the nurse expect in a client diagnosed with Paget's disease? You answered this questionIncorrectly 1. Hearing loss 2. Walking with a limp 3. Muscle weakness 4. A shuffled gait 5. Bow-legged 6. Numbness in lower extremities

1., 2., 5., & 6. Correct: Paget's disease is a chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. An overgrowth of bone in the skull can cause hearing loss or headaches. These clients have severe pain, may walk with a limp, and may become bow-legged. With the spine affected by Paget's disease the lower extremity may have tingling and numbness from spinal nerve root compression. 3. Incorrect: Muscle weakness is not a symptom. 4. Incorrect: This is a manifestation of Parkinson's disease which is related to brain and nerve signals. It is not related to Paget's disease.

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O2 doesn't bring up the BP. 4. Incorrect: Stay away from drugs as long as you can.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? You answered this questionCorrectly 1. Alternating pressure mattress 2. Bath chair 3. Mechanical hoist lift 4. Oxygen 5. Suction equipment 6. Hospital bed

1., 4., 5., & 6 Correct: An alternating pressure mattress will help to prevent pressure ulcers. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. The client with hepatic encephalopathy is unresponsive and may need suctioning if unable to clear secretions from the oropharynx. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. 2. Incorrect: The unresponsive client will not need a bath chair. This client will receive a bed bath. 3. Incorrect: Mechanical hoist lifts are expensive and require special training to use.

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse? You answered this questionIncorrectly 1. Decreased deep tendon reflexes 2. Proteinuria 3. One week weight gain of 1 pound (2.2 kg). 4. Muscle weakness 5. Light sensitivity

1., 2., & 5 Correct: The deep tendon reflexes will be increased (hyperactive) with preeclampsia. Proteinuria, another sign of preeclampsia, is the result of proteins, normally confined to the blood by the filtering role of your kidney, spilling into your urine. This is because preeclampsia temporarily damages this "filter." Albumin, as well as many other proteins, are lost this way. Vision changes are one of the most serious symptoms of preeclampsia. They may be associated with central nervous system irritation or be an indication of swelling of the brain (cerebral edema). Common vision changes include sensations of flashing lights, auras, light sensitivity, or blurry vision or spots. This client is going into preeclampsia. 3. Incorrect: Weight gain of more than 3-5 pounds in a week may be an indicator of preeclampsia. Damaged blood vessels allow more water to leak into and stay in your body's tissue and not to pass through the kidneys to be excreted. 4. Incorrect: Muscle spasms, rather than weakness will occur. This indicates nerve/muscle irritation.

The nurse is to administer oxytocin 0.5 milliunits/min IV to a client admitted for labor induction. Oxytocin is available as 10 units/1000 ml 0.9% normal saline. How many mL/hour of the oxytocin should be administered? You answered this questionIncorrectly 1. 3 mL/hour 2. 6 mL/hour 3. 10 mL/hour 4. 12 mL/hour

1. Correct: 3 mL/hour will deliver oxytocin 0.5 milliunits/min. Calculations for IV Oxytocin Solution NOTE 1 Unit = 1,000 milliunits TO MAKE SINGLE-STRENGTH IV SOLUTION: Add 10 Units of Oxytocin to 1 liter of compatible IV fluid. TO INFUSE: Convert prescribed milliunits/min to mL/hr and set infusion pump. AMOUNT PRESCRIBED: 0.5 milliunits/min CALCULATIONS: 10 Units/1 L = 10,000 milliunits/1,000 mL OR 10 milliunits/1 mL. 10 milliunits/1 mL = 0.5 milliunits/X mL Cross-multiply to get: 0.5 = 10X X = 0.05, so 0.05 mL/min Multiply by 60 minutes to get amount infused per hour. THINK: 0.05 milliunits = 0.05 mL/min 0.05 mL/min x 60 min/hr = 3 mL/hr (0.05 x 60 = 3) Set the infusion pump for 3 mL/hr.

A nurse auscultates for bowel sounds in a client suspected of having a bowel obstruction in the transverse colon. What would the nurse expect to hear in the right lower abdominal quadrant? 1. Hyperactive bowel sounds 2. Absent bowel sounds 3. Hypoactive bowel sounds 4. Normal bowel sounds

1. Correct: Peristalsis should increase in the ascending colon (RLQ) in an attempt to clear the blockage resulting in hyperactive bowel sounds. There will be little or no peristalsis distal to the obstruction (LLQ) resulting in decreased or absent bowel sounds. 2. Incorrect: Bowel sounds should be present proximal to the blockage (RLQ). 3. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction. 4. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction.

A client with a radial fracture reports itching under the cast. What nursing action is appropriate? You answered this questionIncorrectly 1. Apply an ice pack for 10-15 minutes. 2. Slip a plastic spatula in the cast to rub itching area. 3. Sprinkle baby powder into the cast. 4. Elevate the cast on a pillow. 5. Use a blow dryer on cool setting

1., & 5. Correct: These actions will change the sensation of itching. Applying something cool, such as a breeze from a cool blow-dryer, or an ice pack that will not get the cast wet help change the sensation for the client. 2. Incorrect: No objects should be placed under the cast as injury can occur. 3. Incorrect: Avoid applying lotions, oils, deodorant, or powder in or around the cast. The skin can become irritated. 4. Incorrect: Raising the cast on a pillow will help reduce swelling under the cast in the first 24 to 72 hours after a cast is applied, but it does not help with itching.

Which statements should the nurse include when teaching a client about osteomyelitis? You answered this questionIncorrectly 1. Osteomyelitis is a risk factor for people with impaired immune systems. 2. Weight bearing activity is restricted to avoid stress on the affected bone. 3. Intravenous antibiotics will be administered for at least 3 to 6 weeks. 4. The affected extremity will be elevated. 5. Osteomyelitis requires subcutaneous administration of calcitonin.

1., 2, 3., & 4. Correct: Clients who are at high risk for osteomyelitis include those who are poorly nourished, elderly, or obese. Others at risk include those with impaired immune systems and chronic illnesses such as diabetes and rheumatoid arthritis. Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. IV antibiotic therapy is provided for a period of 3-6 weeks with around the clock dosing to maintain a high therapeutic blood level. Elevation of the extremity reduces swelling and thus associated pain. 5. Incorrect: Calcitonin is used for Paget's disease. A disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae.

The charge nurse is evaluating a new nurse, who is preparing to administer a bolus enteral feeding to a client. The client receiving a proton pump inhibitor. The new nurse checks the pH of aspirated gastric fluid to determine feeding tube placement. The pH reading is 6. Which actions taken by the new nurse requires intervention by the charge nurse? You answered this questionIncorrectly 1. Prepares to initiate feeding since pH is 6. 2. Tells the client that the feeding tube needs to be replaced. 3. Notify the primary healthcare provider of the finding. 4. Inspect the aspirated contents for color and consistency. 5. Pushes air into tube to check correct placement.

1., 2., 3., & 5. Correct: These actions are incorrect and requires intervention by the charge nurse. The normal stomach pH value is 1 to 4; however, when a client is receiving medications to decrease stomach acidity, the pH of the gastric aspirate may be as high as 6 and similar to the pH of respiratory secretions. Small intestines aspirates can also have a pH equal to or higher than 6. A pH of 6 does not confirm correct tube placement. It is not necessary to replace the feeding tube at this time. Look at the aspirated contents for color and consistency. There is nothing abnormal to indicate that the primary healthcare provider needs to be notified. Placing air into the tube will not tell you that tube is in correct place. This is not reliable for tube placement. 4. Incorrect: This is a correct action and does not require intervention by the charge nurse. The nurse should inspect the aspirated stomach contents for color and consistency to determine correct feeding tube placement. Gastric contents are cloudy, green, tan, or off-white, bloody or brown.

After a cholecystectomy, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client? You answered this questionIncorrectly 1. Add a serving of fat to meals such as butter. 2. Include a protein with each meal. 3. Take adequate vitamins, iron and calcium. 4. Lie down on left side after meals. 5. Eat at least five small meals per day. 6. Include a nutritional supplement drink with meals.

1., 2., 3., 4., & 5 Correct: Dumping syndrome is associated with meals having a hyperosmolar composition. To decrease hyperosmolar components, you decrease the carbs and electrolytes. Add a serving of fat to meals and snacks such as butter, margarine, gravy, vegetable oils, and salad dressings. Fats slow stomach emptying and may help prevent dumping syndrome. Proteins digest slower and stay in the stomach longer. Vitamins, iron, and calcium may become depleted after stomach surgery and due to dumping syndrome so taking these will help to maintain good health. Lying down on the left side slows emptying of the stomach. Five or six small frequent meals decrease the extremes of the hyperosmolar content and keep a steady blood sugar level. 6. Incorrect: High sugar foods and carbs speed through the GI tract. Limit high-sugar foods such as soda, juice, Ensure, Boost, cakes, pies, candy, doughnuts, cookies, fruit cooked or canned with sugar, honey, jams, jellies.

Which teaching points would the nurse include in a client's nutritional teaching plan to accomplish the goal of a gluten free diet? You answered this questionCorrectly 1. Gluten is a protein found in barley. 2. Potatoes are a starchy food that can be eaten. 3. Milk is restricted on a gluten free diet. 4. Pure, non-contaminated oats are an acceptable grain food that the client can consume. 5. Eating food containing wheat may result in diarrhea. 6. Increase fiber in the diet.

1., 2., 4., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, rye, and wheat. All products containing these grains are to be avoided. The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca. In addition, pure oats that have not been cross-contaminated with wheat, barley and/or rye can be safely consumed by most individuals with celiac disease or other gluten sensitivity. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. Some people do not experience signs and symptoms, but this does not mean it is not damaging their small intestines. Even trace amounts of gluten may be damaging. 3. Incorrect: Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. 6. Incorrect: A reduction in the fiber content of the diet is also frequently recommended.

A client is preparing to be discharged after a total hip replacement. Which client statement would indicate further teaching is needed regarding prevention of hip prosthesis dislocation? You answered this questionIncorrectly 1. "When crossing my legs, I should only cross my unaffected leg over my affected leg." 2. "Exercise includes bending over to touch my toes several times a day." 3. "While lying in bed, I should not turn my affected leg inward." 4. "It is necessary to keep my knees together at all times." 5. "I should not place a pillow between my legs when I sleep."

1., 2., 4., & 5. Correct: These statements are false, so further teaching is needed. The knees should be kept apart to prevent dislocation. Crossing the legs is prohibited as it can cause the hip to pop out of joint. Bending over to touch the toes (over 90 degrees) can cause the hip to pop out of place. Keep legs apart while sleeping. Placing a pillow between the legs will help keep the legs separated. 3. Incorrect: This is an appropriate action to prevent hip prosthesis dislocation. Until the hip prosthesis stabilizes it is necessary to keep the leg in neutral position. Do not rotate leg inward or outward.

A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which new signs and symptoms noted by the nurse would indicate that the client has developed hepatic encephalopathy? You answered this questionIncorrectly 1. A musty breath odor 2. Inability to perform basic math 3. Spider angiomas 4. Sluggish movements 5. Asterixis 6. Myoclonus

1., 2., 4., 5., & 6. Correct: These are signs and symptoms of hepatic encephalopathy, a severe complication of hepatitis and cirrhosis: A musty or sweet breath odor, poor concentration (such as inability to perform basic math), fatigue, slow movement, asterixis (an abnormal tremor consisting of involuntary jerking movements, especially in the hands). Their muscles may jerk involuntarily or after people are exposed to a sudden noise, light, a movement, or another stimulus. This jerking is called myoclonus. These occur due to increasing ammonia levels in the blood. 3. Incorrect: Spider angiomas are m spthe most classical vascular lesion that is sometimes a presenting sign of chronic liver disease such as cirrhosis. The presence of spider angiomas does not indicate that the client has progressed to hepatic encephalopathy.

A client diagnosed with ulcerative colitis has a new prescription for a biologic agent. What is the priority education the nurse needs to make certain the client receives? You answered this questionCorrectly 1. If you miss a dose, take it as soon as you remember. 2. Stay away from people who are sick. 3. Do not receive a live vaccine while using a biologic agent. 4. Common side effects include headache and cold symptoms.

2. Correct: Biologics are immunomodulators which means that they alter the body's immune response. Since these agents can suppress the immune system, making the client more prone to infection. Biologics are used to treat many inflammatory conditions, such as ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis. They can also be used in adults and children to treat Crohn's disease or juvenile idiopathic arthritis. 1. Incorrect: If the client misses a dose of the medicine, they should take it as soon as they remember, and then go back to your regular injection schedule. Do not use extra medicine to make up the missed dose. But this is not the priority at of the options available. 3. Incorrect: Although clients taking a biologic agent should not receive a "live" vaccine, this is not the priority. The vaccine may not work as well during this time, and may not fully protect the client from disease. Live vaccines include measles, mumps, rubella (MMR), polio, rotavirus, typhoid, yellow fever, varicella (chickenpox), or zoster (shingles). 4. Incorrect: Common side effects do include headache and cold symptoms. However, is this the priority for client education? No.

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? You answered this questionCorrectly 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to prevent hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operatively is a normal occurrence, and elevating the foot of the bed along with the use of an ACE wrap will help prevent swelling.

The charge nurse is evaluating the care a staff nurse is providing to a client who has just returned from open carpal tunnel release surgery. Which action by the staff nurse requires intervention by the charge nurse? You answered this questionIncorrectly 1. Monitors the dressing for tightness. 2. Places hand at the level of the heart. 3. Instructs nursing assistant to check vital signs hourly. 4. Performs neurovascular check to extremity. 5. Checks dressing for drainage.

2., & 3. Correct: The hand should be placed above the level of the heart to decrease edema. Vital signs are needed every 15 minutes for the first hour. 1. Incorrect: This is a correct measure. The client's dressing should be monitored for tightness. No need for the charge nurse to intervene. 4. Incorrect: We would worry about compartment syndrome with tightness and excess bleeding with drainage. Neurovascular checks are important with this client and should be done. No need for the charge nurse to intervene. 5. Incorrect: This is a correct measure. The client's dressing should be monitored for drainage. No need for the charge nurse to intervene.

What information should a nurse include when preparing discharge education for a client diagnosed with gastroesophageal reflux disease (GERD)? 1. Foods that may trigger an attack include apple juice, cream cheese, and oatmeal. 2. Lose weight slowly at a rate of 1 kilogram per week. 3. Only eat three small meals per day. 4. Avoid tight-fitting clothing. 5. Wait at least 1 hour after eating to lie down.

2., & 4. Correct: Excess pounds (kg) put pressure on the abdomen, pushing up the stomach and causing acid to back up into the esophagus. Work to slowly lose weight, no more than 1-2 pounds (0.5-1 kg) per week. Avoid tight-fitting clothing. Clothes that fit tightly around the waist put pressure on the abdomen and the lower esophageal sphincter. 1. Incorrect: These foods are safe for the client with GERD to eat. Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine. 3. Incorrect: Eat 6 small meals per day. Avoid eating 3 large meals. 5. Incorrect: Don't lie down immediately after a meal. Wait at least 3 hours after eating. Gastric acid is more likely to go up into the esophagus if the client lies down immediately.

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? You answered this questionIncorrectly 1. Being discharged with a newly inserted pacemaker. 2. Client with hip fracture in buck's traction. 3. One day post lap cholecystectomy requiring assistance to ambulate. 4. With total hip replacement awaiting transfer to nursing home. 5. Transfer from ICU 1 day post DKA

2., 3., & 4. CORRECT: An LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The LPN can take care of a stable client with a hip fracture who is in buck's traction. The client who is one day post lap cholecystectomy and ambulating would be appropriate for an LPN. Also, a client with a total hip replacement awaiting transfer to nursing home would have needs that could be addressed by an LPN, and therefore is a suitable assignment. 1. INCORRECT: This client has a newly implanted pacemaker which is monitoring and pacing the heart. There is a great deal of teaching necessary regarding a pacemaker. This client should be assigned to an RN. 5. INCORRECT: This client has just been transferred from ICU and will require frequent vitals and glucose checks. This client is considered unstable upon transfer and would be assigned to an RN.

A client has been admitted to the orthopedic surgical unit after repair of a fractured right arm and right leg due to a motor vehicle accident. Preoperative vital signs are heart rate 88/min, respiration 16/min, BP 132/86, Temp. 98.6° F (37° C). The unlicensed assistive personnel reports the 2 hour post op vital signs as heart rate 98/min, respirations 20/min, BP 138/88, Temp. 98.6° F (37° C). What are the appropriate nursing interventions? You answered this questionIncorrectly 1. Notify the primary healthcare provider of the change in vital signs. 2. Assess the client for pain using a pain scale. 3. Perform neurovascular check of distal extremities. 4. Instruct the unlicensed assistive personnel to take another blood pressure reading stat. 5. Monitor surgical dressings for drainage.

2., 3., & 5. Correct: Acute pain is a nursing diagnosis that can be associated with this client's elevated BP and heart rate. Since pain is suspected always do a neurovascular check to assure that pain is not related to neurovascular damage. Dressings must be monitored postop for signs of hemorrhage. 1. Incorrect: Notifying the primary healthcare provider at this time is not necessary. Nursing interventions can address pain and perform neurovascular checks. All vital signs are within normal limits. 4. Incorrect: There is no problem with the blood pressure reading so another stat reading is not necessary. The BP reading may be associated with pain and pain should be assessed and neurovascular checks done.

The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure? You answered this questionIncorrectly 1. Administer small sip of water to assess gag reflex. 2. Monitor for throat pain. 3. Observe for hematemesis. 4. Evaluate bowel elimination frequency. 5. Monitor respiratory effort. 6. Assess oxygen saturation level.

2., 3., 5, & 6. Correct: A gastroscopy examination uses a flexible fiber-optic tube to visualize the esophagus and/or stomach. Accidental perforation of the esophagus may occur during endoscopy. If pain or bleeding occur following the procedure, notify the primary healthcare provider. The nurse should monitor for hematemesis, respirations, and oxygen saturation to ensure the scope did not damage any structures like the esophagus or lungs. 1. Incorrect: The throat is numbed before the procedure to inhibit the gag reflex and to allow the scope to pass freely. Therefore, it is important to maintain NPO status until the gag reflex returns. 3. Incorrect: Because the kidneys are not affected during this procedure, monitoring intake and output is not an important intervention. 4. Incorrect: Because the bowels are not affected during this procedure, this is not an important intervention.

A nurse is planning care for a client admitted to the unit after application of a halo apparatus to immobilize the cervical spine. What interventions should the nurse include? You answered this questionCorrectly 1. Clean around pins once daily with a small brush. 2. Use the log roll technique when turning client in bed. 3. Assist client with daily shower. 4. Have client sit up slowly with assistance. 5. Inspect for skin breakdown under halo vest.

2., 4., & 5. Correct: Turn the client in bed every 2 hours by means of a triple log roll technique, in which 3 nurses roll the client. 1st nurse stands behind the head of the bed and places hands firmly on the client's head and neck, turning them as 1 unit. 2nd nurse stands at the client's side and moves the shoulders. 3rd nurse stand at the client's side and moves the client's hips and legs. All 3 nurses turn the client at the same time into desired position and onto previously positioned pillow. Administer mild analgesics to control headache and discomfort around the pin site. Begin sitting and ambulating by assessing the client's tolerance to upright position, accompany the client when ambulating, and consider the client's use of a walker. Inspect skin under halo vest looking for skin breakdown. 1. Incorrect: Clean around pins at least twice daily with sterile q-tips. A brush may cause abrasions on the skin. 3. Incorrect. Assist client with a sponge bath to help keep the vest dry. Showers will cause the vest to become wet and should not be taken. This can lead to skin breakdown.

A client who is three days post-op cholecystectomy complains of severe abdominal pain. During the initial morning assessment the client states, "I had two almost black stools last night." Which nursing action is the most important? You answered this questionCorrectly 1. Start an IV with D5W at 125 mL/hr 2. Insert a nasogastric tube 3. Contact the primary healthcare provider 4. Obtain a stool specimen

3. Correct: What's going on inside? They are hemorrhaging. Assume the worst. The primary healthcare provider is the only one who can stop the bleeding. 1. Incorrect: There's nothing wrong with starting an IV, but isn't the client bleeding while you do this? 2. Incorrect: How does that help the bleeding stop? It doesn't. 4. Incorrect: You are going to wait on a stool specimen and Hemoccult? Don't delay care! Notify the primary healthcare provider first.

In which client should the nurse initiate a prescription for a contraction stress test? You answered this questionIncorrectly 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa. 6. Client with preterm membrane rupture

3., & 4. Correct: There is no reason to suspect complications from a contraction stress test for these clients. The nurse should proceed with the test. 1. Incorrect: 6 weeks is too early to stimulate contractions. This could lead to a preterm delivery. 2. Incorrect: Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. 5. Incorrect: Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 6. Incorrect: Conditions such as preterm membrane rupture may increase risk of preterm labor and delivery.

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? You answered this questionCorrectly 1. Onset of nausea and vomiting 2. Contraction every 3 minutes, lasting 20 seconds 3. Maternal blood pressure 140/90 4. Late decelerations in the fetal heart rate

4. Correct: Late decelerations are a serious condition in which the heart rate of a fetus lowers below baseline usually after the peak of a contraction and signifies impaired placental exchange of blood flow and oxygen to the fetus. Late decelerations requires medical intervention on the part of a healthcare professional because the status of the infant is likely compromised. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 2. Incorrect: There is nothing wrong with these contractions. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome.

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. You answered this questionIncorrectly The Correct Order Elevate head of bed to Fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward. Rotate catheter and pass the tube into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.

First, raise the client's head of bed to fowler's position Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches (5.08-7.62 cm) of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward. Sixth, rotate catheter and advance into nasopharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. During this process, the tube is advanced past the nasopharynx. The client is then asked to take sips of water or swallow ice chips to help with tube advancement into the stomach. Finally, the tube is taped once placement is assured. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.