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Questions 158

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Question 1 of 5

A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

Correct Answer: C

Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.

Question 2 of 5

A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:

Correct Answer: C

Rationale: Analgesic medication does not counteract the effects of antibiotics. Analgesic medication may lower blood pressure elevated due to anxiety. Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. Analgesics do not stimulate the CNS.

Question 3 of 5

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:

Correct Answer: B

Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.

Question 4 of 5

Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

Correct Answer: D

Rationale: A recurrent fetal heart rate of 90-100 bpm at the end of contractions (late decelerations) is ominous indicating fetal hypoxia from uteroplacental insufficiency. Normal heart rate (120-130) variability and accelerations are reassuring findings.

Question 5 of 5

A client with a history of heart failure is receiving Carvedilol (Coreg). The nurse should monitor the client for:

Correct Answer: A

Rationale: Carvedilol, a beta-blocker, can cause hypotension due to vasodilation and reduced heart rate. Hyperglycemia, tachycardia, and weight gain are not primary concerns.

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