The nurse is caring for a client in active labor who is 8 centimeters dilated and who reports the need to push. The nurse instructs the client not to push until:
1. True contractions have begun.
2. The cervix is 9-10 cm dilated
3. The membranes have ruptured.
4. The cervix is fully dilated.
4
Rationale: Pushing before fully dilated can result in injury to the cervix and edema that will preclude complete dilation.
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A nurse who functions proficiently in her area of specialization is considered to be in which stage of the Colorado Differentiated Practice Model clinical ladder?
a. Stage I c. Stage III b. Stage II d. Stage IV
A patient with glaucoma is taking a beta-adrenergic blocking agent, timolol (Timoptic). For which potential side effect should the nurse assess the patient?
a. Wheezing b. Hypertension c. Sudden eye pain d. Blurred vision
The nurse recognizes that the risk for dehydration in the elderly increases significantly due to which age-related change in renal function?
1. decreased ability of the kidney to concentrate urine 2. hypoplasia 3. presence of renal cysts 4. reduced clearance of drugs excreted by the kidney
As the nurse continues to care for the client during the working phase of the therapeutic relationship, the client's needs change. What nursing action is appropriate at this time?
A) Reminisce about the client's progress. B) Restate the purpose of the relationship. C) Address confidentiality issues. D) Revise the plan of care as needed.