Exhibits

Choose the most likely options missing from the statements by selecting from the list of options provided.

The nurse teaches the client about the fetus reactions to labor by
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. The nurse will assess the fetus reaction by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

• Describing contractions: Focuses on uterine activity and helps assess labor progress, but it does not provide information about how the fetus is coping with labor. Fetal reaction requires assessment of fetal-specific indicators, not maternal contraction patterns.

• Describing heart rate patterns: Offers clear information about how the fetus is responding to labor. Changes in fetal heart rate such as variability, accelerations, and decelerations help detect fetal hypoxia or distress during contractions.

• Assessing mother’s vital signs: Important for monitoring maternal status, but it does not give any direct indication of fetal well-being. Vital signs like blood pressure or temperature reflect maternal condition, not fetal response.

• Performing vaginal examination: Useful for tracking cervical dilation, effacement, and fetal station, but does not assess the fetus’s adaptation to labor. It informs labor progress, not fetal oxygenation or stress levels.

• Continuous fetal monitoring: Provides continuous data on fetal heart rate patterns in relation to contractions. It allows early detection of fetal distress, helping guide interventions that promote safe labor and delivery.

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Correct Answer is D

Explanation

A. Recommend the use of supplemental liquid feedings: Liquid feedings might eventually be needed if swallowing becomes too difficult, but immediate action should focus on preventing aspiration during meals rather than altering the diet.

B. Assist the client to lie down and turn to the side: Lying down during eating increases the risk of aspiration and should be avoided; an upright position is essential to maintain airway protection during swallowing.

C. Encourage the use of assistive feeding devices: Assistive devices help compensate for weakness in the hands and arms but do not directly address the swallowing difficulties that are causing coughing during meals.

D. Demonstrate use of a tucked-chin position while eating: Tucking the chin while swallowing helps protect the airway by closing it off, reducing the risk of aspiration, and is an immediate, practical strategy to enhance safe swallowing in ALS clients.

A. Determine if the client needs to have a gait belt applied. B. Offer to assist the client to void prior to walking in the hall. C. Instruct the client about signs of orthostatic hypotension. D. Report the onset of any dizziness or light headedness. E. Measure the client's vital signs before the client walks.

Correct Answer is ["B","D","E"]

Explanation

A. Determine if the client needs to have a gait belt applied: Deciding on the need for a gait belt requires nursing judgment and should be assessed by the nurse, not delegated to the UAP.

B. Offer to assist the client to void prior to walking in the hall: Voiding before ambulation helps prevent urgency, falls, and discomfort during the walk and is an appropriate task to delegate to a UAP.

C. Instruct the client about signs of orthostatic hypotension: Teaching is a nursing responsibility and should not be delegated to the UAP; the nurse should explain these signs to the client.

D. Report the onset of any dizziness or light headedness: UAPs should be instructed to monitor and report signs of distress during ambulation, such as dizziness, which could indicate orthostatic hypotension or fatigue.

E. Measure the client's vital signs before the client walks: Checking and reporting vital signs before activity is within the UAP’s scope and helps ensure the client's readiness for walking.

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Exhibits Choose the most likely options missing from the statements by selecting from the list of options provided. The nurse teaches the client about the fetus reactions to labor by dropdown . The nurse will assess the fetus reaction by dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Correct Answer is D

Explanation

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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Exhibits

Choose the most likely options missing from the statements by selecting from the list of options provided.

The nurse teaches the client about the fetus reactions to labor by
dropdown
. The nurse will assess the fetus reaction by
dropdown
.