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Questions 158

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Question 1 of 5

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When assessing the client’s response to the Pitocin, the nurse should give priority to:

Correct Answer: B

Rationale: Pitocin can cause uterine hyperstimulation, risking fetal distress. Checking the fetal heart rate is the priority to ensure fetal well-being. Blood pressure, contractions, and urinary output are monitored but are secondary to fetal status.

Question 2 of 5

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:

Correct Answer: A

Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.

Question 3 of 5

The nurse is caring for a patient hospitalized with leukopenia. Which of the following assessments should be reported to the physician immediately?

Correct Answer: C

Rationale: A temperature increase to 99.8°F in a patient with leukopenia (low white blood cell count) may indicate an infection which is a medical emergency due to the patient’s compromised immune system. The other vital signs are within normal limits and less urgent.

Question 4 of 5

A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:

Correct Answer: C

Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.

Question 5 of 5

A client with a history of chronic lymphocytic leukemia is admitted with complaints of lymphadenopathy. The nurse should give priority to:

Correct Answer: A

Rationale: Lymphadenopathy in chronic lymphocytic leukemia increases infection risk, so monitoring for infection is the priority.

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