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Question 1 of 5

The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?

Correct Answer: A

Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.

Question 2 of 5

The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.

Correct Answer: B, C

Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.

Question 3 of 5

A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

Correct Answer: C

Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.

Question 4 of 5

A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:

Correct Answer: B

Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.

Question 5 of 5

The nurse is preparing to administer a dose of hydralazine (Apresoline) to a client with hypertension. The client’s blood pressure is 90/60 mmHg. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: hydralazine is a vasodilator, and a blood pressure of 90/60 mmHg indicates hypotension, so the dose should be withheld

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