A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
a. The acme
b. The interval
c. The increment
d. The decrement
ANS: A
The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.
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The nurse explains to a patient that based on the description of "personal space," the area within 18 inches of the patient is designated as the ____________ zone
ANS:
The RN from the previous shift reports that the traction on her client for a fractured femur doesn't look "right". You enter the room to perform an assessment of the client's traction. This will include:
a. examining the pulleys to make sure the rope is aligned correctly b. remove the weight to help the client move up in the bed c. rest the weight on the client's bed to assist with the assessment d. add more weight to assist with improved alignment
A person who is receiving tests to confirm a diagnosis of Alzheimer's disease is preparing for a computerized tomography (CT) test. The patient becomes restless and is unable to follow the pre-examination directions given by the lab personnel
As the nurse who is assisting the patient, your best action at this time is: A) Tell the patient that refusing to cooperate will require having to return another day B) Give the patient the written instructions C) Take the patient to a quiet waiting area until it is time for the CT scan D) Make certain that the patient is tightly strapped to the examination table during the test
The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip?
1. Late decelerations 2. Early decelerations 3. Accelerations 4. Increased long-term variability