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Questions 158

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Question 1 of 5

A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:

Correct Answer: A

Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.

Question 2 of 5

The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?

Correct Answer: C

Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.

Question 3 of 5

The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?

Correct Answer: D

Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.

Question 4 of 5

A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:

Correct Answer: B

Rationale: The Trendelenburg position reduces air embolism risk by increasing central venous pressure and distending veins for easier catheter insertion.

Question 5 of 5

Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer: A

Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.

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