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- 1. A nurse is assessing a client who is at 37 weeks of gestation. Which of the followingstatement by the client requires immediate intervention by the nurse?A. “It burns when I urinate.”B. “My feet are really swollen today.”C. “I didn’t have lunch today, but I have breakfasted this morning.”D. “I have been seeing spot this morning.”A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.The practical nurse (PN) is participating in a health promotion program for a group of adults at a health fair about life style choices. Which information is most important for the PN to emphasize? A Perform monthly self examination of breasts and testes. B Eat a diet high in fruits, vegetables, and whole grains. C Completely stop the use of cigarette and tobacco products.D Avoid the midday sun and use sunscreen.
- 2. Draw and trace the pathway of fetal circulation (HAND DRAWN) 3. Give at least 5 assessments of fetal well-being: 3.1 Description/definition 3.2 indications 3.3. Expected results1. A pregnant client, gravida 1 para 0, comes to the labor and delivery area stating that she thinks she is in labor. She reports short, somewhat irregular contractions occurring in the lower portion of the abdomen that seem to lessen when she walks. Her estimated date of delivery is tomorrow. a. Is the client experiencing true labor? Why or why not? b. What information would be most important for the nurse to explain to the client about labor? 2, 3, 4 2. A postpartum client who is breastfeeding calls the clinic because her breasts have become quite tender. She is 4 days postpartum and is told to come to the clinic for evaluation. At the clinic, assessment reveals that her breasts are shiny and red, hard, and very warm to the touch. Her nipples are intact and her temperature is slightly elevated. The newborn has been feeding well and appears satisfied after breastfeeding. a. What would the nurse explain as the underlying condition occurring? b. What measures would be important for the…A client delivered 4 hours ago. The nurse assesses the client and finds the following: fundus firm at the level of the umbilicus, moderate amount of lochia rubra and midline episiotomy well approximated . The nurse understands that fourth stage nursing care for the client includes which of the following ? a. Inspection every 15 minutes during the first hours after childbirth b. Ice pack to the perineum for up to 60 minutes per application c. Instructions to avoid intercourse for at least 12 weeks d. Application of ice beginning 4 hours after delivery
- 1. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the BEST understanding of the nature of the surgery if the client makes which of the following statements? a."I will need to drain the pouch regularly with a catheter." b."I will be able to pass stool from my rectum eventually." c."The drainage from this type of ostomy will be formed." d."I will need to wear a drainage bag for the rest of my life." 2. After ileostomy surgery, the nurse assesses the abdomen of the patient and notices that the stoma is purplish red. The nurse should: a.Report this finding to the surgeon immediately b.Apply warm soaks to the stoma to improve circulation c.Reassure the patient that this is the normal color. d.Watch the stoma for any further changes in color 3. Which client would be MOST likely to have the diagnosis of diverticulosis? a.A 40-year-old male with a family history of diverticulosis. b.A 65-year-old…1. A nurse is caring for an adolescent who is 1 hour post-operative followingan appendectomy. Which of the following findings should the nurse report to theprovider?a. Heart rate 63 / minuteb. muscle rigidityc. temperature 36.4 Celsius (97.5 Fahrenheit)d. abdominal painOn assessment the nurse note that the fetus is developing fetal distress. Immediately the nurse place the mother to which best position to relieve compression of the vena cava and to promote venous return. A. Dorsal Recumbent position B. Turn mother to the left side and elevate the legs C. Turn the mother to the right side and flex the leg D. Supine position
- .A nurse is caring for a client who is in the first stage of labor with report of ruptured membranes prior to admission to the labor unit. The nurse observes the fetal heart rate changes baseline from 150/min to 110/min. during a vaginal exam. The nurse notes a pulsation at the cervix. Which of the following actions should the nurse perform first? Push the cord back into the cervical os Prepare the woman for immediate vaginal birth Place the client in the supine position Insert a gloved hand into the vagina to lift the presenting part off of the cord.The nurse is caring for a toddler with large, unrepaired ventricular septal defect and heart failure. Which assessment findings should the nurse expect? A. Hypotension B. Tachycardia 45) @ She 46) Am to I U 9 В states that when she kisses her baby, the intants skin taste saltv. 2 C. Pulse oximetry reading within defined limits. D. Blood pressure variance across extremities #3 L 54 $ R 07 2⁰ % 5 T 6 are Y & U in * 00 ( -O Tics PASSI11. The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? A. The cuff is wrapped loosely around the arm. B. The cuff is placed about 1 in above the antecubital area. C. The bladder inside the cuff encircles 50% of the arm circumference. D. The nurse can fit three to four fingers under the inflated cuff. Explain each choices why it is and why it is not the answer