a nurse is caring for a client who is in active labor and notes late decelerations in the fhr on the external fetal monitor which of the following act
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PN ATI Capstone Maternal Newborn

1. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.

2. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

Correct answer: B

Rationale: Clients with chronic kidney disease often have difficulty regulating potassium levels in their blood. A potassium-restricted diet helps prevent hyperkalemia, a common complication in these clients. High sodium diet (Choice A) is typically avoided in kidney disease to prevent fluid retention and high blood pressure. High phosphorus diet (Choice C) is usually restricted in kidney disease as elevated phosphorus levels can lead to bone and heart problems. While protein is important for overall health, a high protein diet (Choice D) can put extra strain on the kidneys and is usually limited in chronic kidney disease.

3. A nurse is caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.

4. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer?

Correct answer: A

Rationale: In the scenario of a client experiencing prolonged seizures, such as status epilepticus, the priority is to administer a benzodiazepine to stop the seizure activity. Diazepam is the medication of choice for this situation due to its rapid onset of action and effectiveness in terminating seizures quickly. Lorazepam, although another benzodiazepine, is typically given through routes other than oral (PO) administration in emergency situations. Diltiazem is a calcium channel blocker used for cardiac conditions, not for seizure management. Clonazepam is a benzodiazepine, but it is usually not the first choice in the acute management of status epilepticus.

5. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?

Correct answer: B

Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.

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