A nurse in an antepartum unit is caring for a client.
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Nurses' Notes
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Client rates pain with contractions as a 3 on a scale of 0 to 10
FHR 150/min with moderate variability. Accelerations present, no decelerations noted
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
The Correct Answer is ["A","B","C","D","E"]
- Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
- Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
- Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
- Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
- FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia.
B. Seeing dark spots is not a common or expected outcome. Some clients may experience temporary blurriness, but not dark spots.
C. Bruising of the eyelids is not a typical side effect of cataract removal. There may be mild swelling or redness, but significant bruising is unusual.
D. Cataract removal involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore clear vision. This statement shows the client understands the procedure.
Correct Answer is C
Explanation
A. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.
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