NCLEX EXAM PREVIEW

NCLEX EXAM PREVIEW The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the 1. first stage of labor who has an oral temperature of 99.7° F (37.6° C) 2. first stage of labor whose contractions are occurring every 30 seconds 3. second stage of labor who has respirations of 26 4. second stage of labor whose contractions are lasting for 60 seconds - correct answer -2. first stage of labor whose contractions are occurring every 30 seconds Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs) 90 secs is the duration, 2 mins is the frequency. Rationale: 1. Elevated temp is normal during labor 3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern 4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain The nurse is observing a staff member caring for a client who has chickenpox. Which of the following actions by the staff member would require the nurse to intervene? 1. placing the client in a private room with monitored negative air pressure 2. placing a box of disposable face shields outside the client's room 3. placing an alcohol-based hand rub in the client's room for hand hygiene 4. placing a surgical mask on the client during transport out of the client's room - correct answer -2. placing a box of disposable face shields outside the client's room disposable face masks are not suitable for airborne precautions Rationale: Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing surgic