The membranes of a pregnant patient have ruptured and the umbilical cord is hanging out of the vagina. What should the nurse do?
A) Place the patient in bed, call for help, and hold the presenting part of the cord
B) Place the patient in the lithotomy position, hold and sharply flex the legs toward the shoulders
C) Ask another nurse to confirm that the cord is in the vagina
D) Prepare the patient for a vaginal delivery
Ans: A
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The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery three hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak
The first action of the nurse is to: 1. Assist the client to empty her bladder. 2. Help the client back to bed to check her fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer's solution.
The nurse is reviewing the medical record of a child diagnosed with septic arthritis. Which of the following would the nurse expect to find? Select all answers that apply
A) Elevated neutrophil count B) Decreased C-reactive protein level C) Joint fluid with increased white blood cells D) Decreased joint space with radiograph E) Increased erythrocyte sedimentation rate
The nurse observes a client with head bowed and hands folded seemingly in prayer. The nurse recognizes this as an example of:
1. Nonverbal communication 2. Interpersonal communication 3. Intrapersonal communication 4. Transpersonal communication
The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?
a. The patient awakens easily. b. The patient's eyes rapidly move. c. The patient is difficult to awaken. d. The patient's vital signs are elevated.