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Questions 158

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Question 1 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 2 of 5

A client is being admitted to the labor and delivery unit. She has had previous admissions for 'false labor.' Which clinical manifestation would be most indicative of true labor?

Correct Answer: B

Rationale: Contractions of true labor produce progressive cervical effacement and dilatation.

Question 3 of 5

Which meal selection is most appropriate for a patient with iron deficiency anemia?

Correct Answer: C

Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.

Question 4 of 5

While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

Correct Answer: C

Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.

Question 5 of 5

The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:

Correct Answer: B

Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.

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