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 »
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: A. Notify her doctor B. Start an IV C. Reposition the client D. Readjust the monitor Correct Answer: C. Reposition the client The initial action by the nurse observing a late… Read More »
Which of the following is a characteristic of a reassuring fetal heart rate pattern? A. A fetal heart rate of 170–180 bpm B. A baseline variability of 25–35 bpm C. Ominous periodic changes D. Acceleration of FHR with fetal movements Correct Answer: D. Acceleration of FHR with… Read More »
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is: A. The bladder fills more rapidly because of the medication used for the epidural. B. Her level of consciousness is such that she is in a trancelike state. C. The sensation of the bladder filling is… Read More »
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client Correct Answer: B. Check the… Read More »
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden, stabbing pain in the lower quadrant Correct Answer: D. Sudden, stabbing… Read More »