A nurse is caring for a client.
Complete the following sentence by using the lists of options.
The nurse understands that the patient has likely developed
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
- Lithium toxicity: The client's lithium level is significantly elevated at 2.5 mEq/L (normal range is 0.6 to 1.2 mEq/L), and symptoms such as blurred vision, increased urine output, and clonic jerking of the upper extremities are indicative of lithium toxicity2.
- Seizure activity: Lithium toxicity can lead to neurological symptoms, including seizures, which require close monitoring
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Generativity vs. Self-absorption is the stage for adults in middle adulthood (ages 40-65), where individuals focus on contributing to society and guiding the next generation.
B. According to Erikson’s stages of psychosocial development, adolescents (ages 12-18) are in the stage of Identity vs. Role Confusion. During this stage, they work to develop a sense of personal identity and to explore different roles and beliefs.
C. Intimacy vs. Isolation occurs in young adulthood (ages 18-40), where individuals seek to form intimate relationships.
D. Trust vs. Mistrust is the first stage of Erikson’s theory, occurring during infancy (0-18 months), where infants develop a sense of trust when their needs are consistently met.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
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