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A nurse in an antepartum unit is caring for a client.

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, not for those with bacterial meningitis.
B. Droplet. This is correct because bacterial meningitis is transmitted through respiratory secretions. Droplet precautions, including wearing a mask when within 3 to 6 feet of the client, are necessary to prevent the spread of infection.
C. Contact. This is incorrect because bacterial meningitis is not primarily transmitted through direct contact with surfaces or bodily fluids, making contact precautions unnecessary.
D. Airborne. This is incorrect because bacterial meningitis does not spread through airborne particles that remain suspended in the air, so airborne precautions are not required.

A. "I can use chamomile tea to promote sleep." B. "Herbal medicines do not interact with conventional medications." C. "I can use ginger to help treat headaches." D. "Herbal medicines are regulated by the Food and Drug Administration."

Correct Answer is A

Explanation

A. "I can use chamomile tea to promote sleep." Chamomile has calming properties and is commonly used as a natural remedy to promote relaxation and improve sleep.
B. "Herbal medicines do not interact with conventional medications." Many herbs can interact with prescription medications, potentially causing harmful effects.
C. "I can use ginger to help treat headaches." Ginger is primarily used to reduce nausea and motion sickness rather than for headache relief.
D. "Herbal medicines are regulated by the Food and Drug Administration." Herbal supplements are not regulated by the FDA in the same way as prescription and over-the-counter medications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?

Correct Answer is B

Explanation

A nurse is providing teaching to a group of clients about complementary and alternative therapies using herbs. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?

A nurse in an antepartum unit is caring for a client. Exhibits For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.