A patient has been in labor for five hours. Earlier
there was a gradual increase in FHR baseline with variables, but the patient has changed position several times and now the fetus shows no signs of hypoxia. The cervix is almost completely effaced and is dilated to 8 cm. However, the labor graph indicates that the fetus has stopped descending. What should the nurse do first?
A) Inform the physician that internal fetal monitoring may be needed
B) Palpate the area just above the symphysis pubis
C) Institute effleurage and apply pressure to the patient's lower back during contractions
D) Encourage the patient to push
Ans: B
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A nurse is caring for a group of clients and will perform each of the following during the next shift. For which of the following is informed consent required?
A) Ordering a liquid diet for a post-surgical patient B) Listening to a patient reveal his or her private, personal secrets C) Giving a patient saline solution to relieve dry nasal passages D) Asking a patient to complete a questionnaire for a research study on hospital practices
The nurse is planning care for an older adult client with type 2 diabetes mellitus. Which nursing diagnosis would be most appropriate for this client?
A) Risk for Falls B) Risk for Infection C) Ineffective Tissue Perfusion: Cardiac D) Impaired Tissue Integrity
A client with ADHD is prescribed methylphenidate (Ritalin). Based on the half-life of the drug, how often should the nurse administer the drug?
a. Daily b. Twice a day c. Every 8 hours d. Every 12 hours
While being comforted in the emergency department, the 6-year-old male sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" Which response by the
nurse is most therapeutic? 1. Asking the child if he would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that he can draw a picture 3. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens 4. Discussing the catheters, tubes, and equipment that the sibling requires, and explaining why they are needed