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Questions 158

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Question 1 of 5

A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

Correct Answer: A

Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.

Question 2 of 5

A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:

Correct Answer: B

Rationale: A contraction stress test is unnecessary following a reactive (normal) nonstress test. The results are considered reactive, indicating that the fetus is not showing distress.
Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.

Question 3 of 5

The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?

Correct Answer: A

Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.

Question 4 of 5

The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?

Correct Answer: A

Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.

Question 5 of 5

The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:

Correct Answer: B

Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.

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