After performing a vaginal exam, the nurse determines that a client is in the second stage of labor. The situation that best confirms the nurse's judgment is when the woman's
a. cervix is completely dilated
b. contractions are every 3 minutes lasting 60 seconds
c. fetal head is engaged
d. membranes have ruptured
A
The second stage of labor begins when the cervix is completely dilated and effaced. Contractions every 3 minutes lasting 60 seconds describes the contractions of the active phase of the first stage of labor. The fetal head is engaged earlier, in the first stage of labor. Rupture of the membranes may occur at the onset of labor, or an artificial amniotomy may be performed during the first stage of labor. It is not a defining point of the second stage.
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A 25-year-old Asian American man arrives in the emergency room in a panic. Except for a bout with bronchitis a week earlier, he has been healthy his entire life; today he has blood in his urine
What disease has likely caused of his hematuria and how should it be treated? A) Goodpasture syndrome and will be treated with plasmapheresis and immunosuppressive therapy B) Membranous glomerulonephritis and should be treated with corticosteroids C) Immunoglobulin A nephropathy and may be advised to use omega-3 fatty acids to delay progression of disease D) Kimmelstiel-Wilson syndrome and should be treated with medication to control high blood pressure
The nurse is assessing a client using the Nutritional Screening Initiative Tool. Which information would increase the client's score on this screening tool?
a. Takes atenolol daily b. Requires assistance of one person to bathe c. Maintained weight over last 7 years within 5 pounds d. Receives visits from daughter and grandchildren three times each week
Postoperative teaching for a client who has a vasectomy would emphasize which of the following?
a. Apply ice to the scrotum for 1 hour following surgery. b. Avoid strenuous physical exercise for one week. c. Rest at least 24 hours after surgery. d. Other contraceptive devices are unnecessary as the sperm pathway has been severed.
The nurse is working in a clinic setting and is meeting a new client for the first time. In order to convey cultural sensitivity, how should the nurse introduce herself?
1. "I'm Jane, and I'll be your nurse today." 2. "I'm Dr. Smith's nurse, Jane." 3. "I'm Jane Brown, and I'm a nurse here at the clinic." 4. "I'm glad to meet you. You can call me Jane."