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Question 1 of 5

Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

Correct Answer: D

Rationale: A recurrent fetal heart rate of 90-100 bpm at the end of contractions (late decelerations) is ominous indicating fetal hypoxia from uteroplacental insufficiency. Normal heart rate (120-130) variability and accelerations are reassuring findings.

Question 2 of 5

Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?

Correct Answer: C

Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and
A), and zinc. Baked chicken breast (protein), broccoli (vitamin
C), wheat roll (carbohydrates), and an orange (vitamin
C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).

Question 3 of 5

A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Correct Answer: D

Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

Question 4 of 5

The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?

Correct Answer: D

Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (
A) are less specific, sunbathing at peak hours (
B) increases risk, and routine mole removal (
C) is excessive.

Question 5 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

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The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
The client is admitted at 32 weeks gestation with a diagnosis of gestational hypertension. Which assessment finding is most significant?

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