A nurse is caring for a client in active labor.
Admission Assessment.
0200:. Gravida 1, Para 0 at 39 weeks gestation.
Presents with.
contractions occurring every 5 to 6 min, 45 to 60 seconds.
duration.
Cervical examination 4 cm dilated, 50% effaced.
Admit.
to the labor and delivery unit.
Nurses' Notes.
0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.
of O to 10 with contractions.
Cervix 4 cm dilated, 50% effaced,with membranes intact.
0230:. The client reports increasing discomfort with contractions.
Cervix 5. cm dilated, 60% effaced, with membranes intact.
Contractions.
occurring every 5 min, 45 to 60 seconds duration.
0300:. Epidural anesthesia was initiated.
Cervix 7 cm dilated, 70% effaced,. with membranes intact.
Contractions occur every 4 to 5 min,60 seconds duration.
Vital Signs.
0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.
Respiratory rate 18/min.
BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.
Respiratory rate 20/min.
BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.
Respiratory rate 18/min.
BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.
For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.
Assess for urinary retention.
Encourage the client to turn from side to side.
Monitor for elevated temperature.
Inform the client to expect drowsiness.
Assist the client with ambulation.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct Answer is A
Explanation
Choice A rationale:
Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.
Choice B rationale:
Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.
Choice C rationale:
White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.
Choice D rationale:
Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.
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