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Questions 158

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Question 1 of 5

While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:

Correct Answer: D

Rationale: Early decelerations are benign, caused by fetal head compression during labor, and require only documentation, as they do not indicate fetal distress.

Question 2 of 5

A laboratory technique specific for diagnosing Lyme disease is:

Correct Answer: A

Rationale: Polymerase chain reaction is the laboratory technique specific for Lyme disease. Heterophil antibody test is used to diagnose mononucleosis. Lyme disease does not decrease the serum calcium level. Lyme disease does not increase the serum potassium level.

Question 3 of 5

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

Correct Answer: B

Rationale: Offering a pacifier can disrupt the surgical repair of a cleft lip by placing pressure on the suture line. Holding, providing a mobile, and offering sterile water are safe and comforting.

Question 4 of 5

The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

Correct Answer: A

Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature (
B) is important but secondary, low hematocrit (
C) is not a goal, and 300 mL/hr urine output (
D) is excessive.

Question 5 of 5

A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:

Correct Answer: C

Rationale: Using Nägele's rule, subtract 3 months and add 7 days from January 15, resulting in October 22.

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