更多"A client at term arrives at the lab"的相关试题:
[单项选择]A client at term arrives at the labor room experiencing contractions every 4 minutes. After a brief assessment, she’s admitted and an electronic fetal monitor is applied. Which of the following would alert the nurse to an increased potential for fetal distress
A. Weight gain of 30 lb (13.6 kg).
B. Maternal age of 32 years.
C. Blood pressure of 146/90 mmHg.
D. Treatment for syphilis at 15 weeks’ gestation.
[单项选择]A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time
A. Impaired skin integrity related to inability to move lower extremities.
B. Impaired urinary elimination related to the effects of the epidural.
C. Deficient knowledge related to lack of information about regional anesthesia.
D. Risk for injury related to hypotension secondary to vasodilation and pooling in extremities.
[单项选择]A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor
A. Discomfort located chiefly in the abdomen.
B. Constant intensity of contractions.
C. Contractions occurring every 10 to 15 minutes and lasting 20 to 30 seconds.
D. Cervix that is 100% effaced and 2 cm dilate
[单项选择]A client with hypotonic labor dysfunction is receiving oxytoein augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at station +1. The nurse notes a soft bulge just above the symphysis. Which of the following actions is best
A. Re-evaluate the fetal presentation.
B. Change the client’s position.
C. Offer a narcotic analgesic.
D. Help the client urinat
[单项选择]Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation
A. Breech position.
B. Late decelerations.
C. Entrance into the second stage of labor.
D. Multiple gestation.
[单项选择]A multigravid client in active labor is about to deliver. The nurse has no help immediately available. What should the nurse do first
A. Prepare a clean area on which to deliver the neonate.
B. Lower the head of the bed to a flat position.
C. Have the client push with a contraction.
D. Ask the client to take a deep breath and hold it.
[单项选择]A 24-year-old client on the labor unit is being coached in the Lamaze method by her husband. On assessment, the nurse finds the client to be 5 cm dilated, 90% effaced, at +1 station with contractions coming every 2 to 3 minutes and lasting 35 to 40 seconds. The client has asked for pain relief. What’s the nurse’s best action
A. Check maternal blood pressure and pulse and fetal heart rate in response to contractions.
B. Realize that it’s too early to give pain medication, and encourage the husband to continue with the Lamaze coaching.
C. Arrange for a sonogram to determine fetal position.
D. Perform a vaginal examination to determine dilation, effacement, and station.
[单项选择]A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer which of the following medication
A. Ritodrine (Yutopar).
B. Bromocriptine (Parlodel).
C. Betamethasone (Celestone).
D. Magnesium sulfat
[单项选择]A client is admitted to the labor and delivery unit in active labor. She has had no prenatal care but appears to be between 32 and 35 weeks’ gestation. History reveals that she’s gravida 5, para 1, abortus 3. She tells the nurse she thinks her friend gave her a cigarette containing crack cocaine. What should the nurse do next
A. Move the precipitant delivery cart to the labor room, and notify the neonatologist on call.
B. Teach the mother controlled breathing techniques.
C. Call a family member to come to the hospital.
D. Call the friend who gave the client the cigarette and find out exactly what the drug was.
[单项选择]The nurse is caring for a client who is in labor. The physician still isn’t present. After the neonate’s head is delivered, which nursing intervention would be most appropriate
A. Checking for the umbilical cord around the neonate’s neck.
B. Placing antibiotic ointment in the neonate’s eyes.
C. Turning the neonate’s head to the side, to drain secretions.
D. Assessing the neonate for respirations.
[单项选择]A client is being admitted to the labor unit. Because she’s well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent
A. Duration of previous labor.
B. Frequency of contractions.
C. Presence of bloody show.
D. Expected due dat
[单项选择]A client receiving morphine for long-term pain management develops tolerance. When the client asks the nurse what it means, which of the following should the nurse response
A. "Tolerance is an allergic reaction to a medication. "
B. "Tolerance is an ability to take the same drug for extended periods of time. "
C. "Tolerance is an increased response to a medication. "
D. "Tolerance is a diminished response to a drug so that more is required to reach the same effect. "
[单项选择]A client is suffering from short-term memory loss after a head injury. Which of the following nursing actions would be appropriate to help him cope with his memory loss
A. Instruct family members to ignore his behavior.
B. Place a single-date calendar where he can view it.
C. Explain that he will have to try harder to remember things.
D. Tell him every morning what activities he will be expected to perform that day.
[单项选择]A 28-year-old client delivered a full-term male neonate one hour ago. Which finding should the nurse expect when palpating the client’s fundus
A. Soft, at the level of the umbilicus.
B. Firm, 2 cm below the umbilicus.
C. Firm, at the level of the umbilicus.
D. Boggy, midway between the umbilicus and symphysis pubis.
[单项选择]The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he’ll be undesirable to his wife, and he becomes tearful. He expresses that he’s spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes
A. Situational low self-esteem.
B. Unilateral neglect.
C. Social isolation.
D. Risk for loneliness.
