A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to: A. Assess the fetal heart tones B. Check for cervical dilation C. Check for firmness of the uterus D. Obtain a detailed history Correct… Read More »
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: A. Her contractions are 2 minutes apart. B. She has back pain and a bloody discharge. C. She experiences abdominal pain and frequent urination. … Read More »
The client with color blindness will most likely have problems distinguishing which of the following colors? A. Orange B. Violet C. Red D. White Correct Answer: B. Violet Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The most common forms are protanopia and… Read More »
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered: A. Within 72 hours of delivery B. Within 1 week of delivery C. Within 2 weeks of delivery D.… Read More »
After the physician performs an amniotomy, the nurse’s first action should be to assess the: A. Degree of cervical dilation B. Fetal heart tones C. Client’s vital signs D. Client’s level of discomfort Correct Answer: B. Fetal heart tones When the membranes rupture, there is often a transient drop… Read More »
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor? A. Active B. Latent C. Transition D. Early … Read More »
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit? A. Pain B. Misalignment C. Cool extremity D. Absence of pedal pulses Correct Answer: B. Misalignment The client with a hip fracture will most likely have a… Read More »
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly? A. The infant no longer complains of pain. B. The buttocks are 15° off the bed. C. The legs are suspended in the traction.… Read More »
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. Utilizes a Steinman pin B. Requires that both legs be secured C. Utilizes Kirschner wires D. Is used primarily to heal the fractured hips … Read More »
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: A. Blood pressure B. Temperature C. Output D. Specific gravity Correct Answer: A. Blood pressure Blood pressure is the best… Read More »