A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?
a. Latent phase c. Second stage
b. Active phase d. Third stage
ANS: B
The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. This patient is in the active phase of labor.
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The nurse is caring for a patient from a different culture. After assessing the patient and formulating the care plan, what action by the nurse is best?
a. Review the care plan for acceptance by the patient. b. Delegate appropriate tasks to unlicensed assistive personnel. c. Go over the care plan with the charge nurse. d. Begin implementing the planned interventions.
A stroke patient is having difficulty swallowing food and beverages. The patient complains that he feels like "the food is sticking to the back of his throat." Given this information, the priority nursing interventions would be to
A) make the patient "nothing per os" (NPO) and call the physician. B) feed the patient while he is sitting in an upright position. C) add a thickening agent to all of the patient's beverages. D) warrant no action since this is a normal occurrence after a stroke.
A client is diagnosed with a disorder that has an autosomal dominant inheritance pattern. A review of the client's family history and pedigree does not reveal any ancestors with the disorder. How should the nurse interpret this finding?
1. Errors have been made in the documentation of the client's history. 2. Some ancestors experienced effects that were so minor they were not recognized. 3. A de novo mutation has occurred. 4. The client's genetic testing should be repeated.
An elderly client diagnosed with Type 2 diabetes mellitus frequently reports that his tea is "way too sweet" even though the staff adds only the 1 teaspoon of sugar substitute the client requests
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