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A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Obtain a baseline reading of the FHR and contraction pattern.

Document the procedure in the electronic medical record.

Pass the sterile hook to the provider.

Position the client with a rolled towel under her hips

Check the fluid for color, odor, and consistency

Answer and Explanation

The Correct Answer is A,D,C,E,B

A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

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Correct Answer is B

Explanation

A. "Our child has a better grasp of reality.": This is not the primary goal of methylphenidate. While it may help with focus and attention, the medication's goal is to improve concentration and reduce hyperactive behaviors in children with ADHD, not directly influence their grasp of reality.

B. "Our child is able to complete his homework on time.": This is correct. Methylphenidate, a stimulant used to treat ADHD, helps improve attention, focus, and impulse control. A child who can complete homework on time demonstrates improved attention and task completion, which is the desired outcome.

C. "Our child has lost some weight since his last appointment.": While weight loss can be a side effect of methylphenidate, it is not an indicator that the medication is effective. The goal is to manage ADHD symptoms, not necessarily to cause weight loss.

D. "Our child has increased his daily caloric intake.": This is incorrect. A common side effect of methylphenidate is decreased appetite, so an increase in caloric intake would not be expected.

A. "You should eat three large meals and two snacks per day." B. "You should elevate the head of the bed while sleeping." C. "You should lay down for 1 hour following a meal." D. "You should only drink 2 cups of coffee per day."

Correct Answer is B

Explanation

A. Eating three large meals and two snacks per day is not advisable for GERD patients. Large meals can increase the pressure on the lower esophageal sphincter (LES), leading to acid reflux. It is better to recommend smaller, more frequent meals to reduce symptoms.

B. Elevating the head of the bed while sleeping is correct. Elevating the head of the bed (usually by 6 to 8 inches) helps prevent acid from refluxing into the esophagus during sleep, a key management strategy for GERD.

C. Laying down for 1 hour following a meal is incorrect. After eating, patients with GERD should avoid lying down for at least 2 to 3 hours to prevent acid reflux. Lying down too soon after eating increases the risk of reflux.

D. Drinking 2 cups of coffee per day is not ideal for people with GERD, as caffeine can relax the LES, leading to increased reflux. While the exact amount varies by individual tolerance, it is generally recommended to limit or avoid caffeine.

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A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

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