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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

Correct Answer: B

Rationale: Station refers to the relationship of the presenting part to the ischial spines. A station of -1 indicates the fetal head is 1 cm above the ischial spines.

Question 2 of 5

Which aminophylline level is associated with signs of toxicity?

Correct Answer: D

Rationale: Aminophylline levels above 20 micrograms/mL are toxic, causing symptoms like nausea, tachycardia, or seizures. 25 micrograms/mL is well above the therapeutic range (10-20).

Question 3 of 5

The nurse is teaching a client with a history of atrial fibrillation about medication adherence. The nurse should tell the client to:

Correct Answer: A

Rationale: Anticoagulants reduce stroke risk in atrial fibrillation, so adherence is critical.

Question 4 of 5

The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:

Correct Answer: D

Rationale: Sitz baths after bowel movements promote healing and relieve pain post-hemorrhoidectomy by keeping the area clean and reducing inflammation. High-fiber diets are encouraged, ice packs are typically used earlier, and laxatives may be prescribed but are not the priority.

Question 5 of 5

The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

Correct Answer: C

Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.

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