Exit 7 Flashcards
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
A. Degree of cervical dilation
B. Fetal heart tones
C. Client’s vital signs
D. Client’s level of discomfort
B. Fetal heart tones
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After assessing fetal heart tones, the nurse should evaluate cervical dilation, vital signs, and level of discomfort.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment, the client is in which phase of labor?
A. Active
B. Latent
C. Transition
D. Early
A. Active
The active phase of labor occurs when the client is dilated 4–7 cm. The latent or early phase of labor is from 1 cm to 3 cm in dilation, and the transition phase of labor is 8–10 cm in dilation.
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
A. Teaching the mother to provide tactile stimulation
B. Wrapping the newborn snugly in a blanket
C. Placing the newborn in the infant seat
D. Initiating an early infant-stimulation program
B. Wrapping the newborn snugly in a blanket
The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or providing for early infant stimulation is incorrect because the infant is irritable and needs quiet and little stimulation at this time. Placing the infant in an infant seat is incorrect because this will also cause movement that can increase muscle irritability.
Tactile therapy stimulation, or tactile stimulation, refers to using touch to promote a positive sensory experience for individuals with special needs.
Tactile stimulation includes the activating of nerve signals beneath the skin’s surface that inform the body of texture, temperature and other touch-sensations (warming, drying, rubbing).
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
A. Checking for cervical dilation
B. Placing the client in a supine position
C. Checking the client’s blood pressure
D. Obtaining a fetal heart rate
C. Checking the client’s blood pressure
Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client should not be positioned supine because the anesthesia can move above the respiratory center, causing respiratory arrest. Fetal heart tones should be assessed after checking the blood pressure.
The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:
A. Administer a prescribed antibiotic
B. Wash her hands for 2 minutes before care
C. Wear a mask when providing care
D. Ask the client to cover her mouth when she coughs
B. Wash her hands for 2 minutes before care
The best way to prevent postoperative wound infection is hand washing. Use of prescribed antibiotics will treat infections, not prevent them. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections.
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
A. Pain
B. Disalignment
C. Cool extremity
D. Absence of pedal pulses
B. Disalignment
The client with a hip fracture will most likely have misalignment. Pain is common to all fractures. Coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease, not typically seen with hip fractures.
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
A. Lack of exercise
B. Hormonal disturbances
C. Lack of calcium
D. Genetic predisposition
B. Hormonal disturbances
After menopause, women lack hormones necessary to absorb and utilize calcium. Weight-bearing exercises and calcium supplements can help prevent osteoporosis but are not primary causes. Thin Caucasian females are more susceptible, but hormonal disturbances are a significant factor.
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
A. The infant no longer complains of pain
B. The buttocks are 15° off the bed
C. The legs are suspended in the traction
D. The pins are secured within the pulley
B. The buttocks are 15° off the bed
The infant’s hips should be off the bed approximately 15° in Bryant’s traction. This positioning indicates the traction is working correctly. Bryant’s traction is a skin traction, not a skeletal traction, and pins are not used.
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
A. Utilizes a Steinman pin
B. Requires that both legs be secured
C. Utilizes Kirschner wires
D. Is used primarily to heal fractured hips
A. Utilizes a Steinman pin
Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Only the affected leg is in traction. Kirschner wires are used to stabilize small bones such as fingers and toes. Buck’s traction is not used for fractured hips.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
A. Serum collection (Davol) drain
B. Client’s pain
C. Nutritional status
D. Immobilizer
A. Serum collection (Davol) drain
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Pain assessment, nutritional status, and immobilizer checks are important but secondary to monitoring for hemorrhage.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching?
A. “I must flush the tube with water after feedings and clamp the tube.”
B. “I must check placement four times per day.”
C. “I will report to the doctor any signs of indigestion.”
D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”
A. “I must flush the tube with water after feedings and clamp the tube.”
The client’s family member should be taught to flush the tube after each feeding and clamp the tube. Placement should be checked before feedings. Indigestion can occur but is not a reason for alarm, and feeding discontinuation should not be solely based on swallowing ability.
The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor?
A. Bleeding on the dressing is 3 cm in diameter
B. The client has a temperature of 100.6°F (38.1°C)
C. The client’s hematocrit is 26%
D. The urinary output has been 60 during the last 2 hours
C. The client’s hematocrit is 26%
The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2 cm on the dressing is not extreme, a low-grade temperature is not unusual post-surgery, and urinary output is adequate.
The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
A. The client has traveled out of the country in the last 6 months
B. The client’s parents are skilled stained-glass artists
C. The client lives in a house built in 1976
D. The client has several brothers and sisters
B. The client’s parents are skilled stained-glass artists
Plumbism is lead poisoning. One factor associated with lead consumption is working with stained glass, as lead is used to put it together. Traveling out of the country does not increase the risk, houses built after 1976 typically do not have lead paint, and having several siblings is unrelated.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
A. High-seat commode
B. Recliner
C. TENS unit
D. Abduction pillow
A. High-seat commode
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but is not primarily used for daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. An abduction pillow is used to prevent adduction of the hip and possible dislocation of the prosthesis.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
A. Administer oxygen via nasal cannula
B. Have narcan (naloxone) available
C. Prepare to administer blood products
D. Prepare to do cardio resuscitation
B. Have narcan (naloxone) available
Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardiac resuscitation without further information.
