A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A toddler who has a laceration on his forehead and is crying

An adolescent female client who is belligerent and has slurred speech

A young adult with a painful sunburn of his face and arms

A middle adult male who is diaphoretic and reports epigastric pain

Answer and Explanation

The Correct Answer is D

A. A laceration on the forehead of a toddler, while needing attention, is not as urgent as symptoms suggestive of a myocardial infarction.
B. Belligerence and slurred speech in an adolescent could indicate substance use or neurological issues, but it is less immediately life-threatening than symptoms of a myocardial infarction.
C. While painful sunburn can be uncomfortable, it is not as critical as symptoms indicative of a potential heart attack.
D. Diaphoresis and epigastric pain can be symptoms of a myocardial infarction (heart attack), which is a potentially life-threatening condition requiring immediate medical attention.

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Correct Answer is B

Explanation

A. While iron is important during pregnancy, increasing iron intake does not specifically reduce the risk of neural tube defects.
B. Folic acid is crucial in reducing the risk of neural tube defects, and consuming foods fortified with folic acid or taking supplements is recommended for women planning to become pregnant.
C. Limiting alcohol consumption is important for overall fetal health but does not specifically prevent neural tube defects.
D. Avoiding foods containing aspartame is not necessary for reducing the risk of neural tube defects; the focus should be on folic acid intake.

A. Left lower B. Right upper C. Right lower D. Left upper

Correct Answer is C

Explanation

A. If the round, firm, moveable part is in the fundus and the long, smooth surface is on the right side, the fetal back is likely on the right side, making the fetal heart tones more audible in the right lower quadrant.
B. The right upper quadrant is less likely to have clear fetal heart tones if the fetal back is on the right side; this quadrant is typically less optimal for auscultation in this scenario.
C. Given the fetal back is on the right side, the fetal heart tones are best heard in the right lower quadrant, where the back is more prominent.
D. The left upper quadrant would not be the best place to auscultate the fetal heart tones if the fetal back is on the right side.

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A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is C

Explanation

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence.

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?