1. The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130bpm
Answer B is correct. Absent variability is not normal and could indicate a neurological problem. Answers A, C, and D are normal findings. 246. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips might be allowed, although this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase, not the early phase of labor. Answers B and C are not correct because clients during labor are allowed to change position as she desires.
2. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
A. Cheese omelet
B. Whole-wheat bread
C. Hamburger on wheat bun with ketchup
D. Spaghetti
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130bpm
Answer B is correct. Absent variability is not normal and could indicate a neurological problem. Answers A, C, and D are normal findings. 246. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips might be allowed, although this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase, not the early phase of labor. Answers B and C are not correct because clients during labor are allowed to change position as she desires.
A. Cheese omelet
B. Whole-wheat bread
C. Hamburger on wheat bun with ketchup
D. Spaghetti
Answer A is correct. The child with celiac disease should be on a gluten-free diet. Answer D is the only choice of foods that do not contain gluten. Therefore, answers A, B, and C are incorrect.
3. Which nurse should be assigned to care for the postpartal client with preeclampsia?
A. The RN with 2 weeks of experience in postpartum
B. The RN with 10 years of experience in surgery
C. The RN with 3 years of experience in labor and delivery
D. The RN with 1 year of experience in the neonatal intensive care unit
Answer C is correct. The nurse in answer B has the most experience in knowing possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.
4. Which action by the healthcare worker indicates a need for further teaching?
A. The nursing assistant wears gloves while giving the client a bath.
B. The nurse wears gloves to take the client’s vital signs.
C. The doctor washes his hands before examining the client.
D. The nurse wears goggles while drawing blood from the client.
Answer B is correct.
It is not necessary to wear gloves when taking the vital signs of the client, thus indicating further teaching for the nursing assistant. If the client has an active infection with methicillin-resistant staphylococcus aureus, gloves should be worn, but this is not indicated in this instance. The actions in answers A, B, and C are incorrect because they are indicative of infection control not mentioned in the question.
A. The RN with 2 weeks of experience in postpartum
B. The RN with 10 years of experience in surgery
C. The RN with 3 years of experience in labor and delivery
D. The RN with 1 year of experience in the neonatal intensive care unit
Answer C is correct. The nurse in answer B has the most experience in knowing possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.
4. Which action by the healthcare worker indicates a need for further teaching?
A. The nursing assistant wears gloves while giving the client a bath.
B. The nurse wears gloves to take the client’s vital signs.
C. The doctor washes his hands before examining the client.
D. The nurse wears goggles while drawing blood from the client.
Answer B is correct.
It is not necessary to wear gloves when taking the vital signs of the client, thus indicating further teaching for the nursing assistant. If the client has an active infection with methicillin-resistant staphylococcus aureus, gloves should be worn, but this is not indicated in this instance. The actions in answers A, B, and C are incorrect because they are indicative of infection control not mentioned in the question.
Comments
Post a Comment