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

Rationale: The correct actions for the nurse to take are A, C, D, F, and G. Administering oxygen at 10L/min via a nonrebreather face mask is important for respiratory support. Initiating a bolus of IV fluid helps maintain adequate hydration and perfusion. Assisting the client to the left lateral position promotes optimal blood flow to the fetus. Notifying the provider of the client's condition ensures timely intervention. Lastly, preparing to administer an amnioinfusion may be necessary based on the client's condition. These actions prioritize the client's respiratory, circulatory, and fetal well-being. Other choices like requesting hydralazine or oxytocin may not be indicated without proper assessment and prescription.

Correct Answer: B

Rationale: The correct answer is B: Place the client leaning forward over the overbed table. This position helps to expand the intercostal spaces, making it easier to access and aspirate the pleural fluid during thoracentesis. It also reduces the risk of puncturing the diaphragm. A: Scheduling an MRI after the procedure is unnecessary and not related to thoracentesis. C: Encouraging the client to take deep breaths during the procedure is incorrect as it can cause movement and make the procedure more challenging. D: Ensuring the client has been NPO for 6 hours is irrelevant to thoracentesis and not necessary for this procedure.

Correct Answer: B,D

Rationale: The correct answers are B (Fetal heart rate) and D (Characteristics of amniotic fluid) because these findings are critical indicators of fetal well-being. Changes in fetal heart rate may indicate fetal distress, requiring immediate intervention. Monitoring amniotic fluid characteristics is crucial to assess for potential complications like infection or rupture. Blood pressure, fetal station, and contraction duration are important but not as urgent as fetal heart rate and amniotic fluid assessment in this context.

Correct Answer: C

Rationale: The correct answer is C: "Do you ever think about harming yourself?" This question is the priority because it assesses the client's immediate safety and risk of harm. The client's statements indicate feelings of worthlessness and fear of aging badly, which can be associated with depression and suicidal ideation in older adults. By asking about thoughts of self-harm, the nurse can identify if the client is at risk and take appropriate actions to ensure their safety.


Choice A (Did anything in particular make you feel this way?) is not the priority because it focuses on the cause rather than the client's safety.
Choice B (Would you tell me more about the changes you see in your body?) is also not the priority as it does not address the client's emotional distress.
Choice D (How long have you had these feelings of uselessness?) is important but not as urgent as assessing for suicidal thoughts.

Correct Answer: C

Rationale: The correct response is C: "You must be feeling very frightened right now." This acknowledges the client's emotions without making assumptions about the cause or offering unsolicited advice. It shows empathy and validates the client's feelings, which is essential in counseling.
Choice A is too vague and does not address the client's emotional state.
Choice B puts the client on the spot and may come off as confrontational.
Choice D is dismissive and invalidates the client's emotions by suggesting they simply think positively. By choosing option C, the nurse demonstrates active listening and creates a supportive environment for the client to express their feelings further.