The client asks the nurse, "When does the first stage of labor end?" The MOST appropriate response by the nurse would be when the:
a. cervical dilation is 4 centimeters
b. cervical dilation is 10 centimeters
c. crowning occurs
d. uterine contractions occur every 5 to 7 minutes
B
The first stage of labor is dilation and effacement. This stage begins with the onset of labor and ends when cervical dilation is complete at 10 cm. This stage is further divided into three phases: latent, active, and transition. The latent phase ends when the cervix is dilated 4 cm. This is a good time to teach the client because she is usually still fairly comfortable. The active phase begins when the cervix is dilated 4 cm and ends when the cervix is dilated 8 cm. The client will focus on breathing techniques and is less receptive to teaching. The transition phase begins when the cervix is dilated 8 cm and ends when the cervix is 10 cm.
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A 15-year-old patient suffered a head injury as the result of a bicycle accident. The nurse is concerned about potential fluid complications caused by the injury. What should the nurse monitor most closely?
a. Aldosterone release b. Urine output c. Renin release d. Body temperature
In what group decision making technique are the members not present?
a. PERT c. Delphi b. Gantt d. Nominal
A patient is being treated for pinworms with anthelmintics. In addition to taking the medication, what should the nurse be sure to cover during the teaching session?
a. Wash the toilet seat weekly. b. There are special diet requirements before taking this medication. c. There is no need to test other family members for this condition. d. You may have diarrhea and abdominal pain while taking this medication.
The nurse has instructed a client recovering from a pulmonary embolism on long-term anticoagulant therapy. Which client statement indicates that instruction has been effective?
A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor, and avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."