A patient is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning
A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the patient is in which phase of labor? 1. Active
2. Latent
3. Transition
4. Fourth
3
Rationale 1: In the active phase, the woman dilates from 4 to 7 centimeters.
Rationale 2: The latent phase is the beginning of labor contractions.
Rationale 3: The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer together and more intense.
Rationale 4: There is no fourth phase. The fourth stage occurs after delivery of the placenta.
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1. It suggests an endocrine disorder. 2. It may indicate a malignancy. 3. It suggests a breast infection. 4. It is usually indicative of lactation.
A client has generalized anxiety disorder but is otherwise healthy. He is receiving buspirone daily
The topic that would be excluded from the health teaching plan is a. the importance of daily aerobic exercise. b. avoidance of foods and drinks containing caffeine. c. effects and side effects of buspirone. d. how to prevent the occurrence of flashbacks.
The client with cirrhosis is given lactulose (Cephulac), which causes diarrhea. The client asks the nurse why it is necessary to take this medication. The nurse explains that the medication will:
A) prevent gastrointestinal bleeding. B) reduce serum ammonia levels. C) promote excess fluid loss. D) prevent constipation.
A patient who is taking nicardipine (Cardene) develops skin lesions, itching, fever, and achy joints. What is your best first action?
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