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Question 1 of 5

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Correct Answer: D

Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

Question 2 of 5

A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.

Order the Items

Source Container

Obtain assistance; three nurses are preferable.
Maintain client's position in alignment with pillows.
Position two nurses on the side the client will be turned to and the third nurse on the opposite side of the bed.
Designate the person at the head of the bed to be in charge of coordinating the move.
Place a pillow between the client's knees.
Move the client in one coordinated movement when the nurse at the head of the bed signals to move the client.
Instruct the client to place the arms across the chest.

Correct Answer: A, C, D, G, E, B, F

Rationale: Log rolling sequence: Obtain assistance (
A), position nurses (
C), designate leader (
D), instruct arm placement (G), place pillow (E), align with pillows (
B), move coordinately (F).

Question 3 of 5

A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

Correct Answer: D

Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.

Question 4 of 5

When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

Correct Answer: C

Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.

Question 5 of 5

The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?

Correct Answer: A

Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (
B), chocolate chip cookies (
C), and bran cereal (
D) contain gluten.

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