While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
a. Persistent fetal bradycardia below 100
b. Maternal pulse rate of 100
c. Maternal blood pressure of 120/70
d. Decreased intensity of uterine contractions
A
Fetal bradycardia may indicate fetal distress and may require immediate intervention.
Maternal pulse rate may increase due to the pushing process.
This blood pressure is within expected norms for this stage of labor.
The birth is imminent at this point.
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The nurse admits a client diagnosed with chronic renal failure who will receive a kidney transplant. The nurse begins to prepare the family for discharge needs by:
1. Discussing the need for infection-control measures post-transplant. 2. Discussing the need for reduced activity after the procedure. 3. Questioning the parents about their knowledge of antirejection drugs. 4. Explaining how to change the surgical dressing postprocedure.
The action by a psychiatric nurse that supports the client's right to be treated with dignity and
respect is when the nurse a. addresses the client by his title and surname (e.g., Mr. Jones). b. discusses the client's condition with his physician as they have lunch in the cafeteria. c. tells the treatment team that the client is too drowsy to be consulted about the plan of care. d. strongly encourages the client to participate in recreational activities available on the unit.
The nurse is caring for a client who presents with achy jaw pain. Which assessment technique does the nurse use to determine whether the client has inflammation of the temporomandibular joint (TMJ)?
a. Checking for decayed, fractured, loose, or missing teeth b. Observing the jaw joint as the client chews a piece of food c. Palpating the joint during movement for tenderness or crepitus d. Observing for asymmetric joint protrusion when the client's mouth is closed
Patient factors that contribute to antiretroviral therapy (ART) failure include:
1. Being a male who has sex with males 2. HIV diagnosis in pregnancy 3. Good compliance with the ART treatment regimen 4. ART adverse effects