Immediately after rupture of the amniotic membranes, the nurse should assess:
a. Fetal heart tones
b. Maternal blood pressure
c. Contraction duration
d. Cervical dilation
ANS: A
When the amniotic membranes rupture, the umbilical cord can prolapse though the cervical opening. This prevents normal blood flow through the cord, leading to fetal distress.
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A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time
A nurse is preparing to administer a medication by IV bolus through an existing IV line. What is the correct order for administering the medication? (Separate letters by a comma and space as follows: A, B, C, D.)
a. Perform hand hygiene and apply gloves. b. Aspirate for blood return before injecting the medication. c. Occlude the IV line by pinching the tubing just above the injection port. d. Verify the specified time recommendation for administration of this medication.
Process analysis is the best choice for research when the researcher would like to do which of the following?
A) Assess a clinical intervention B) Describe program implementation C) Identify a net impact D) Weigh a program's benefits against its monetary costs
A patient's nasopharyngeal culture results are positive for B. pertussis. What actions should the nurse take for this patient?
Select all that apply. 1. restrict fluids 2. monitor intake and output 3. place in respiratory isolation 4. administer erythromycin as prescribed 5. report the test results to the local health department