After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what?
1. Increase the mother's oxygen rate.
2. Turn the mother to the left lateral position.
3. Prepare the mother for a higher-risk delivery.
4. Increase the intravenous infusion rate.
3
Explanation: 3. Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk.
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The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)
a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine.
Which statement, if made by an older adult patient, would require further teaching by the nurse?
1. "Nonprescription drugs will not interfere with my prescribed medications." 2. "I can get non-childproof lids for my pills from the pharmacist." 3. "Alcohol can affect drug action." 4. "I will report any signs of drug toxicity to my doctor."
The nurse administers a tuberculin screening test to a patient who has no known risk factors for tuberculosis. When the test site is read 48 hours later, which result is considered positive?
a. Induration of 2 mm or more b. Induration of 5 mm or more c. Induration of 10 mm or more d. Induration of 15 mm or more
When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next?
A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain.