A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority
for the nurse to collect following an amniotomy?
Amniotic fluid color
The client's temperature
Frequency of contractions
Fetal heart rate
The Correct Answer is D
The priority data for the nurse to collect following an amniotomy is the fetal heart rate. This is an important nursing intervention to assess fetal well-being and identify any potential complications.
a) Assessing the color of the amniotic fluid is important, but it is not the highest priority.
b) Monitoring the client's temperature is important, but it is not the highest priority.
c) Assessing the frequency of contractions is important, but it is not the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct technique for using an albuterol MDI involves closing the mouth around the mouthpiece to create a seal. This helps ensure that the medication is delivered directly into the lungs and maximizes its effectiveness. It also helps prevent the medication from escaping and being wasted.
"Exhale immediately after inhaling": This instruction is not accurate. After closing the mouth around the mouthpiece and activating the inhaler to release the medication, the client should inhale slowly and deeply through the mouth, holding their breath for about 10 seconds if possible. Exhaling immediately after inhaling would not allow enough time for the medication to be absorbed effectively.
"Tilt your head forward while inhaling": Tilted head position is not necessary when using an albuterol MDI. The client should hold the inhaler in an upright position, with the mouthpiece directed toward their mouth. This allows for proper delivery of the medication.
"Take three quick breaths while depressing the canister": This instruction is not accurate for using an albuterol MDI. The correct technique involves taking a slow and deep breath in through the mouth, while simultaneously depressing the canister to release the medication. Taking three quick breaths may not allow enough time for adequate medication delivery.
Correct Answer is A
Explanation
A nurse caring for a client who is receiving total parenteral nutrition should identify that a serum calcium level of 12.5 mg/dL indicates a possible complication of this therapy. Total parenteral nutrition can result in electrolyte imbalances, including hypercalcemia (high levels of calcium in the blood).
The other laboratory results are within normal ranges and do not indicate a complication of total parenteral nutrition.
b) A BUN level of 16 mg/dL is within the normal range.
c) A serum potassium level of 4.6 mEq/L is within the normal range.
d) A WBC count of 8,000/mm³ is within the normal range.
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