Extract:

Client in labor showing late decelerations on the electronic fetal monitor

Question 1 of 5

A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor. What should be the nurse's initial course of action?

A. Insert an IV catheter.B. Assist the client into the left-lateral position.C. Apply a fetal scalp electrode.D. Perform a vaginal exam.

Correct Answer: B

Rationale: The left-lateral position improves uteroplacental blood flow, addressing fetal hypoxia indicated by late decelerations.

Extract:

Postpartum client with fundus displaced laterally to the right and uterine atony

Question 2 of 5

A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is found to be displaced laterally to the right, and there is uterine atony. Which of the following is the cause of the uterine atony?

A. Urinary retentionB. Poor involutionC. InfectionD. Hemorrhage

Correct Answer: A

Rationale: Urinary retention can displace the uterus, preventing proper contraction and leading to uterine atony.

Extract:

Client in prenatal clinic with weight gain concerns

Question 3 of 5

A nurse in a prenatal clinic is attending to a group of clients. Which client's weight gain should the nurse be concerned about?

A. A client with an 18kg (4 lb) weight gain in her first trimester.B. A client with a 68 kg (15 lb) weight gain in her second trimester.C. A client with a 13 kg (25 lb) weight gain in her third trimester.D. A client with a 3.6 kg (8 lb) weight gain in her first trimester.

Correct Answer: A

Rationale: An 18kg weight gain in the first trimester far exceeds the expected 1.8kg, suggesting potential health issues requiring evaluation.

Extract:

6-month-old infant receiving digoxin

Question 4 of 5

A nurse is preparing to administer digoxin to a 6-month-old infant. Before administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

A. 90 beats per minute

Correct Answer: A

Rationale: A heart rate below 90 bpm in infants indicates potential digoxin toxicity risk, requiring the dose to be withheld.

Extract:

8-year-old child diagnosed with acute rheumatic fever

Question 5 of 5

A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse's immediate priority assessment after admission?

A. Identifying the level of parental anxiety related to the diagnosisB. Auscultating the rate and characteristics of the child's heart soundsC. Using a pain-rating tool to evaluate the severity of the joint painD. Assessing the client's erythematous rash

Correct Answer: B

Rationale: Auscultating heart sounds is critical due to the risk of cardiac complications like carditis in acute rheumatic fever.