The practical nurse (PN) is assigned to assist in the care of a client at 34-weeks gestation with premature rupture of membranes (PROM). Four hours after admission, the PN recognizes an increasing trend in the maternal heart rate. Which action should the PN take?

Follow contact precautions when providing care.

Insert a urinary catheter to monitor hourly output.

Encourage the client to push with the next contraction.

Initiate oxygen via face mask at 8 to 10 L/min.

Answer and Explanation

The Correct Answer is D

An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.

Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.

Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.

Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.

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Correct Answer is D

Explanation

Feeling sad or having a depressed mood is a common symptom of depression. Asking the client if they often feel sad can help the practical nurse (PN) assess for depression.

While recent stresses (A), sleep changes (B), and dietary habits (C) may also be relevant to the client's situation, asking if the client often feels sad is the most important question for the PN to ask in order to further assess for depression.

A. Decreased activity level and change in aﬀect. B. Periodic sighing and shaking the head. C. Repeated requests for attention from the nurse. D. Argumentativeness and use of profanity.

Correct Answer is D

Explanation

The most important behaviors for the practical nurse (PN) to monitor in this situation are argumentativeness and use of profanity. These behaviors may indicate that the client is becoming agitated and may pose a risk to themselves or others. The PN should closely monitor the client's behavior and take appropriate action to ensure the safety of the client and others on the unit. The other behaviors listed may also be important to monitor, but argumentativeness and use of profanity are the most important in this situation

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The practical nurse (PN) is assigned to assist in the care of a client at 34-weeks gestation with premature rupture of membranes (PROM). Four hours after admission, the PN recognizes an increasing trend in the maternal heart rate. Which action should the PN take?

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Naxlex Comprehensive Predictor Exams

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the practical nurse (PN) to ask?

Correct Answer is D

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the practical nurse (PN) to monitor?

Correct Answer is D

Explanation

A client at 8-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the practical nurse (PN) take?

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A highly successful businessman presents to a mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The mother of a child who is hospitalized with croup and is in a mist tent brings the child's favorite stuﬀed animal to the hospital. Which action should the practical nurse (PN) take?

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The practical nurse (PN) is caring for a toddler during a follow-up visit after corticosteroid treatment for minimal change nephrotic syndrome (MCNS). Which finding should the PN recognize as an early sign of relapse?

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Following a hysterectomy, an older adult's complete metabolic panel findings indicate that her magnesium level is low. To help increase the client's magnesium level, the PN should suggest that the client increase her intake of which food?