The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction.
Which intervention should the PN implement first?

Administer oxygen at 10 L/face mask.

Discontinue oxytocin infusion.

Observe perineum for cord prolapse.

Reposition the client laterally.

Answer and Explanation

The Correct Answer is D

Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A.   Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B.   Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C.   Observing perineum for cord prolapse is not necessary in this scenario.

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Correct Answer is A

Explanation

During pregnancy, it is important for the client to consume a balanced and nutritious diet that includes adequate protein, vitamins, and minerals. However, clients with nausea and vomiting may have difficulty tolerating certain foods, particularly those that are high in fat or spicy. Cheeseburgers and French fries are typically high in fat and can exacerbate nausea, making them a poor choice for a client with this symptom.

Baked chicken with rice and pasta with steamed vegetables are both healthier options that can provide the client with adequate nutrition.

Baked potato chips and lemonade may be a suitable snack for some clients, but the high salt content of the chips may exacerbate ﬂuid retention, which can be a concern for clients with pyelonephritis. The PN should encourage the client to choose healthier options and avoid foods that are likely to exacerbate her symptoms.

A. Current administration of analgesics or antianxiety medications. B. History of situational depression related to major life events. C. Previous episodes of frequent falls. D. The client's history of alcohol abuse.

Correct Answer is A

Explanation

The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.

Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.

Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.

Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.

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The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction. Which intervention should the PN implement first?

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Naxlex Comprehensive Predictor Exams

A primigravida who is at 10-weeks gestation is hospitalized on the antepartum unit for pyelonephritis. The client tells the practical nurse (PN) that she has had several episodes of nausea. When reviewing her lunch menu, which food should the PN discourage her from choosing?

Correct Answer is A

Explanation

An older female client is admited to the orthopedic unit following surgical repair of a fractured hip. On the second postoperative day, the client becomes confused and repeatedly asks the practical nurse (PN) where she is. Which information should the PN obtain before reporting to the charge nurse?

Correct Answer is A

Explanation

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The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction.
Which intervention should the PN implement first?