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1. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct answer: B
Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.
2. The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?
- A. Encourage continued use of the 3-point crutch gait by the client
- B. Encourage the client to use a wheelchair for mobility
- C. Instruct the client in the use of a 4-point crutch gait
- D. Instruct the client in the use of a 2-point crutch gait
Correct answer: C
Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.
3. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?
- A. From the peak of one contraction to the peak of the next contraction
- B. From the beginning of one contraction to the end of that contraction
- C. From the beginning of one contraction to the beginning of the next contraction
- D. From the end of one contraction to the beginning of the next contraction
Correct answer: C
Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.
4. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg?
- A. Dorsiflexes the right foot and left foot on command
- B. A 3 by 5 cm ecchymosis area on the right calf
- C. Right calf is 3 cm larger in circumference than the left calf
- D. Bilateral lower extremities have 3+ pitting edema
Correct answer: C
Rationale: The correct answer is C because a significant difference in calf circumference between the legs is a classic sign of DVT. This is due to the obstruction of blood flow in the deep veins of the leg, leading to swelling in the affected limb. Choices A, B, and D are not typical findings of DVT. Choice A describes a neurological response, choice B indicates a bruise on the right calf, and choice D describes pitting edema in both lower extremities, which are not specific signs of DVT.
5. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)
- A. Sausage patties and eggs
- B. Whole wheat toast and jam
- C. Bagels and cream cheese
- D. Blackberries and oatmeal
Correct answer: B
Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.
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