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RN HESI NUTRITION EXIT
A client in the first stage of labor is using a shallow pattern of rapid breaths that
is twice the normal adult breathing rate. The client complains of feeling light
headed, dizzy, and states that her fingers are tingling. What action should the
nurse implement?
-notify the HCP
-help her breathe into a paper bag
-administer oxygen via nasal cannula
-tell the client to show her breathing - - ANS - -B. Help her breathe into a paper bag
A client in active labor at 39-weeks gestation tells the nurse she feels a wet
sensation on the perineum. The nurse notices pale, straw-colored fluid with small
white particles. After reviewing the fetal monitor strip for fetal disturbance, what
action should the nurse take?
-escort the client to the bathroom
-offer the client a bed pan
-perform a nitrazine test
-clean the perineal area - - ANS - -C. Perform a nitrazine test
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting
an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is
inserted. The intrauterine pressure is 65 to 70 mmHg at the peak. Based on this
,information, what action should the nurse implement?
,-notify HCP
-bring delivery table to room
-prepare to administer oxytocin
-document findings - - ANS - -D. Document the findings in the client record
A multiparous client has been in labor for 8 hours when her membranes rupture.
What action should the nurse implement first?
-prepare client for imminent birth
-asses FHR and pattern
-document characteristics of fluid
-notify HCP - - ANS - -B. Assess the fetal heart rate and pattern
Which action should the nurse implement caring for a newborn immediately after
birth?
-keep newborn airway clear
-foster parent-newborn attachment
-administer eye prophylaxis and vitamin k
-dry the newborn and wrapping in blanket - - ANS - -A. Keep the newborn's
airway clear
During an assessment of a multiparous client who delivered an 8 lb 7 oz infant 4
hours ago, the nurse notes the client's perineal pad is completely saturated within
15 minutes. What action should the nurse implement next?
-perform fundal massage
-assess bp
, -notify the HCP
-encourage the client to void - - ANS - -A. Perform fundal massage
The nurse is assessing a full-term newborn's breathing pattern. Which findings
should the nurse assess further? (Select all that apply) - - ANS - -B. Chest
breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with a stethoscope
What action should the nurse implement when caring for a newborn receiving
phototherapy?
-reposition every 6 hr
-place eye shield over eyes
-limit intake of formula
-apply oil based lotion to skin - - ANS - -B. Place an eyeshield over the eyes
Which finding indicates to the nurse that a 4 day old infant is receiving adequate
breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours - - ANS - -B. Saturates 6 to 8 diapers per day