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Ati rn capstone proctored comprehensive assessment exam A
Total Questions : 77
Showing 10 questions, Sign in for more1130:
Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and O station.
1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations.
1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
A nurse is caring for a client who is in active labor.
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
Explanation
Essential Interventions:
- Monitor fetal heart rate
- Administer ampicillin IV
- Place client in left lateral position
- Request a prescription for ephedrine
Contraindicated Intervention:
- Decrease the IV flow rate
Rationale:
- Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
- Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
- Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
- Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
- Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.
A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?
A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?
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