A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
a. There is no dilation
b. The contractions are in the fundus
c. The cervix has softened and effaced
d. The contractions are irregular
ANS: C
One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
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The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance?
A) Place a cool compress on head. B) Elevate the legs higher than the heart. C) Shake the client to arouse. D) Cover the client with a blanket.
A patient is new to sublingual nitroglycerin therapy. Review the following dosage regimens, and choose the one that should be employed when chest pain occurs
a. Take up to five doses; then take two aspirin; and then call the health care provider if pain is not relieved. b. Take one dose; and then call for emergency medical services. c. Take two doses immediately; then take a diuretic; and then call the health care provider if pain is not relieved. d. Take one dose with the onset of chest pain, and then every 5 minutes until a total of three tablets have been taken, and then notify emergency services for assis-tance.
Bacterial infective endocarditis (IE) should be treated with which protocol?
a. Oral antibiotics for 6 months b. Oral antibiotics (penicillin) for 10 full days c. IV antibiotics, diuretics, and digoxin d. IV antibiotics (penicillin type) for 2 to 8 weeks
The nurse notes that Mrs. N., who is Vietnamese, does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, or put him to bed. In evaluating Mrs. N
's behavior with her infant, the nurse realizes that: 1. what appears to be a "lack of interest" in the newborn is, in fact, the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. 2. Mrs. N. is inexperienced in caring for newborns. 3. Mrs. N. needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. 4. extra time needs to be planned for assisting Mrs. N. in bonding with her newborn.