The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first? A. Notify the physician B. Recheck the O2 saturation level in 15 minutes C. Apply oxygen by mask D. Assess… Read More »
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy? A. Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid C. A small amount of greenish fluid D. A… Read More »
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make? A. “We have a name picked out for the baby.” B. “I need to push when I have a contraction.” C. “I can’t concentrate… Read More »
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is: A. Reposition the monitor B. Turn the client to her left side C. Ask the client to ambulate D. Prepare the client for delivery Correct Answer:… Read More »
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: A. A painless delivery B. Cervical effacement C. Infrequent contractions D. Progressive cervical dilation Correct Answer: D. Progressive cervical dilation The expected effect of Pitocin is cervical dilation. Oxytocin is… Read More »
A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage B. Encourage coughing and deep breathing every 2 hours C. Elevate the head of the bed 30° D. Encourage the… Read More »
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? A. Anticipate the need for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Genupectoral position D. Perform an ultrasound exam Correct… Read More »
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is: A. The cervix is closed. B. The membranes are still intact. C. The fetal heart… Read More »
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor? A. Impaired gas exchange related to hyperventilation B. Alteration in placental perfusion related to maternal position C. Impaired physical mobility related to… Read More »
As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern? A. The baby is asleep. B. The umbilical cord is compressed. C. There is a vagal response. D.… Read More »