After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:
A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.” The best response by the nurse would be:
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test:
A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration
for which she is especially at risk is:
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?
What is the appropriate nursing action for a child with increased intracranial pressure?
A client is diagnosed with organic brain disorder. The nursing care should include:
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
