The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions.
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?
A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
B. Discontinue the oxytocin infusion.
C. Insert an indwelling Foley catheter prior to delivery.
D. Prepare abdominal area from below the nipples to below the symphysis pubis are A.
QUESTION 227
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have a Foley.’’ An appropriate response for the RN teaching him would be:
A. “I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.’’
B. “It is not too much trouble. This is the best way to manage urination.’’
C. “OK. I’ll ask your physician if we can replace the Foley.’’
D. “You need to learn this because your doctor ordered it.’’
QUESTION 228
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
A. Impaired communication
B. Sensory-perceptual alterations
C. Altered thought processes
D. Impaired social interaction
QUESTION 229
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is:
A. March 17
B. June 3
C. August 30
D. January 10
QUESTION 230
A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
A. Aspirate gastric contents
B. Auscultate air insufflated through the tube
C. Obtain a chest x-ray
D. Place the tip of the tube under water and observe for air bubbles
QUESTION 231
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?’’ The RN could suggest which one of the following?
A. Push-ups
B. Jumping jacks
C. Leg lifts
D. Kegel exercises
QUESTION 232
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
A. “No, but you must be able to ride on a stationary bicycle while the test is being performed.”
B. “No, but you will have to lie still and the gel that is used may be cool.”
C. “Yes, but your physician will be there and will order pain medicine for you.”
D. “Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.”
QUESTION 233
A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:
A. Place on bed rest; elevate and splint the right knee
B. Apply moist heat to the right knee
C. Administer aspirin for pain
D. Encourage active range of motion to right knee
QUESTION 234
A 24-year-old client presents to the emergency department protesting “I am God.” The nurse identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
QUESTION 235
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
A. Autonomic dysreflexia
B. Bradycardia
C. Central cord syndrome
D. Spinal shock
QUESTION 236
A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
A. 1 gtt/min
B. 5 gtt/min
C. 50 gtt/min
D. 100 gtt/min
QUESTION 237
A client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
A. A diet too high in calories and saturated fat
B. Decreasing cardiac output
C. Decreasing renal function
D. Development of diabetes insipidus
QUESTION 238
The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:
A. Hypertensive crisis
B. Severe rash
C. Severe hypotension
D. Severe diarrhea
QUESTION 239
When planning care for the passive-aggressive client, the nurse includes the following goal:
A. Allow the client to use humor, because this may be the only way this client can express self.
B. Allow the client to express anger by using “I” messages, such as “I was angry when . . .,” etc.
C. Allow the client to have time away from therapeutic responsibilities.
D. Allow the client to give excuses if he forgets to give staff information.
QUESTION 240
A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:
A. Central nervous system damage
B. Hypoglycemia
C. Hyperglycemia
D. These are normal newborn responses to extrauterine life
QUESTION 241
A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:
A. Ideas of reference
B. Delusions of persecution
C. Thought broadcasting
D. Delusions of grandeur
QUESTION 242
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A. Cyanosis
B. Increased respirations
C. Sternal and subcostal retractions
D. Decreased respirations
QUESTION 243
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
A. The physician verifies the exact time of birth.
B. The nurse counts the instruments and sponges with the scrub nurse.
C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn’s eyes.
D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
QUESTION 244
A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.” The best response by the nurse would be:
A. “Describe the people surrounding your house that want to take you away.”
B. “I need more information on why you think others want to use your body for science.”
C. “There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.”
D. “I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.”
QUESTION 245
On admission, the client has signs and symptoms of pulmonary edem
A. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
A. High Fowler
B. Lying on the left side
C. Sitting in a chair
D. Supine with feet elevated
QUESTION 246
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
A. Denial
B. Displacement
C. Regression
D. Projection
QUESTION 247
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
A. An extension of his myocardial infarction
B. Pneumonia
C. Pulmonary edema
D. Pulmonary emboli
QUESTION 248
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
A. Compensated respiratory acidosis
B. Normal blood gases
C. Uncompensated metabolic acidosis
D. Uncompensated respiratory acidosis
QUESTION 249
A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:
A. Prone
B. Supine
C. Side lying
D. Semi-Fowler
QUESTION 250
Assessment of a newborn for Apgar scoring includes observation for:
A. Pupil response
B. Respiratory rate
C. Heart rate
D. Babinski’s reflex
QUESTION 251
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
A. November 7
B. November 10
C. May 7
D. May 10
QUESTION 252
A client’s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client’s COPD. Instructions that should be given to the client include:
A. “Call your physician if you develop palpitations, dizziness, or restlessness.’’
B. “Cigarette smoking may significantly increase the risk for theophylline toxicity.’’
C. “Take this medication on an empty stomach.’’
D. “Do not take your medicine if your pulse is less than 60 beats per minute.’’
QUESTION 253
Which type of insulin can be administered by a continuous IV drip?
A. Humulin N
B. NPH insulin
C. Regular insulin
D. Lente insulin
QUESTION 254
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
A. Mother is concerned about her recovery.
B. Mother calls infant by name.
C. Mother lightly touches infant.
D. Mother is concerned about her weight gain.
QUESTION 255
A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:
A. Bed rest with bathroom privileges will be ordered
B. He will be kept NPO for 8–12 hours
C. Some oozing of blood at the arterial puncture site is normal
D. The leg used for arterial puncture should be kept straight for 8–12 hours
QUESTION 256
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
A. Bonding
B. Maintain normal blood sugar
C. Maintain normal nutrition
D. Monitor intake and output
QUESTION 257
An elective saline abortion has been performed on a 3- week primigravid
A. Following the procedure, the nurse should be alert for which early side effect?
A. Water satiety
B. Thirst
C. Edema
D. Diabetes insipidus
QUESTION 258
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
A. Digoxin (Lanoxin) 0.25 mg po every day
B. Furosemide (Lasix) 40 mg po every morning
C. O22 L/min via nasal cannula
D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
QUESTION 259
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
A. Head of bed elevated 30 degrees on nonoperative side
B. Head of bed elevated 30 degrees on operative side
C. Bed flat on operative side
D. Bed flat on nonoperative side
QUESTION 260
A first-trimester primigravida is diagnosed with anemia.
The nurse should suspect that this anemia is a result of:
A. Mother’s increased blood volume
B. Mother’s decreased blood volume
C. Fetal blood volume increase
D. Increase in iron absorption
QUESTION 261
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
A. Pneumonia
B. Pulmonary contusions
C. Pulmonary edema
D. Tension pneumothorax
QUESTION 262
At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:
A. Hypoglycemia
B. Hyperkalemia
C. Tachycardia
D. Increase in hematocrit and hemoglobin
QUESTION 263
Following a vaginal delivery, the postpartum nurse should observe for:
A. Dystocia, kraurosis
B. Chadwick’s sign
C. Fatigue, hemorrhoids
D. Hemorrhage and infection
QUESTION 264
A physician’s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
A. 5 mg
B. 0.5 mg
C. 0.05 mg
D. 20 mg
QUESTION 265
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
A. pH 7.39
B. White blood cell (WBC) count 10,000 WBCs/mm3
C. Hematocrit 60%
D. Bleeding time of 4 minutes
QUESTION 266
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A. Cover sac with dry sterile dressing
B. Cover sac with saline-soaked sterile dressing
C. Do not apply dressing; keep sac open to air
D. Aspirate any fluid from sac
QUESTION 267
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
A. Allows the physician to visualize the subclavian vein
B. Reduces the possibility of air embolism
C. Reduces the possibility of hematoma formation
D. Makes the procedure more comfortable for the client
QUESTION 268
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
A. Prevent air from entering the pleural space
B. Prevent fluid from entering the pleural space
C. Provide a means to measure chest drainage
D. Provide an indicator of respiratory effort
QUESTION 269
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
A. Bulging fontanelles
B. Seizure
C. Headache
D. Ataxia
QUESTION 270
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
A. Hypertension
B. Hypotension
C. Hypoglycemia
D. Hyperglycemia
QUESTION 271
At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
A. Reinforce an incompetent cervix
B. Repair the amniotic sac
C. Evaluate cephalopelvic disproportion
D. Dilate the cervix
QUESTION 272
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be:
A. “The reason is not known why hypertension is associated with a high-salt diet.”
B. “Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure.”
C. “Salt affects your blood vessels and causes your blood pressure to be high.”
D. “Salt is needed to maintain blood pressure, but too much causes hypertension.”
QUESTION 273
A burn victim’s immunization history is assessed by the nurse. Which immunization is of priority concern?
A. Oral poliovirus vaccine
B. Inactivated poliovirus vaccine
C. Tetanus toxoid
D. Hepatitis B vaccine
QUESTION 274
A 1000-mL dose of D5W 12 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
A. 75 gtt/min
B. 100 gtt/min
C. 125 gtt/min
D. 150 gtt/min
QUESTION 275
A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?
A. Anger
B. Apathy and flatness
C. Smiling
D. Hostility
QUESTION 276
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
A. Smooth, coordinated voluntary movement
B. Tremors
C. Rigidity
D. Muscle weakness
QUESTION 277
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
“
A. Clean his inhaler with warm water and soak it in a 10% bleach solution
B. Drink a glass of water
CSit and rest
D. Use his bronchodilator inhaler
QUESTION 278
At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, “What is the greatest risk to my baby if it is born prematurely?” The RN’s answer should be:
A. Hyperglycemia
B. Hypoglycemia
C. Lack of development of the intestines
D. Lack of development of the lungs
QUESTION 279
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:
A. Maintain routines and usual structure and adhere to schedules.
B. Encourage the client to attend all structured activities on the unit, whether she wants to or not.
C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.
D. Give the client two or three choices to decide what she wants to do.
QUESTION 280
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client’s fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
A. Decreases the overall time of the labor process
B. Prolongs the client’s first stage of labor
C. Decreases the time of the client’s first stage of labor
D. Prolongs the client’s third stage of labor
QUESTION 281
On a mother’s 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:
A. Sims’
B. Fowler’s
C. Prone
D. Any position that the RN chooses
QUESTION 282
A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
A. Reverse Trendelenburg
B. Fowler’s
C. Trendelenburg
D. Sims’
QUESTION 283
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
A. Cold stress
B. Cyanosis
C. Respiratory distress syndrome
D. Seizures
QUESTION 284
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
A. Oxytocin
B. Magnesium sulfate (MgSO4)
C. Ampicillin
D. Tetracycline
QUESTION 285
What is the appropriate nursing action for a child with increased intracranial pressure?
A. Head of bed elevated 45 degrees with child’s head maintained in a neutral position B. Child lying flat
C. Head turned to side
D. Frequent visitation for stimulation
QUESTION 286
A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
A. Ischial spines are the narrowest diameter of the pelvis
B. Ischial spines are the widest diameter of the pelvis
C. They represent the inlet of birth canal
D. They measure pelvic floor
QUESTION 287
A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:
A. Anorexia nervosa
B. Anorexia hysteria
C. Bulimia
D. Conversion reaction
QUESTION 288
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
A. Raise the client’s head and place her feet in a dependent position
B. Notify the physician
C. Place the client on 2 liters of O2 via nasal cannula
D. Administer furosemide (Lasix) 20 mg IV push
QUESTION 289
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial assessment, the best response by the nurse would be:
A. “The fact is you are an alcoholic or you wouldn’t be here.”
B. “I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.”
C. “If you can stop drinking when you want to, why don’t you stop?” D. “It’s good that you can stop drinking when you want to.”
QUESTION 290
A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
A. 125 gtt/min
B. 48 gtt/min
C. 20 gtt/min
D. 21 gtt/min
QUESTION 291
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
QUESTION 292
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
A. Hearing test
(B) Gait
(C) Strabismus
(D) Papilledema
QUESTION 293
A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:
A. Air embolus
B. Circulatory overload
(B) Hypocalcemia
(C) Hypokalemia
QUESTION 294
A young boy tells the nurse, “I don’t like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.” The nurse recognizes this stage of growth and development as:
A. Electra complex
B. Oedipus complex
(C) Superego
(D) Ego
QUESTION 295
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
B. Remove his scalp sutures after 5 days
C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
D. Take meperidine 50 mg po q4–6h prn for headache
QUESTION 296
At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test:
A. “You need to know that an IV is always started before the test.”
B. “You will need to drink 6 to 8 glasses of water to fill your bladder.”
C. “Do not eat any food or drink any liquids before the test is started.”
D. “You will have to remain as still as you possibly can.”
QUESTION 297
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A. Uterine contractions will weaken with walking.”
B. Uterine contractions will strengthen with walking.”
C. The cervix does not dilate.”
D. The fetus does not descend.”
QUESTION 298
After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as:
A. A reactive test
B. A nonreactive test
C. An unsatisfactory test
D. A negative test
QUESTION 299
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8-
(B) endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A. Inappropriate endotracheal tube size
(B) Left-sided pneumothorax
(C) Right mainstem bronchus intubation
(D) Pneumonia
QUESTION 300
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
A. One centimeter below the ischial spines
B. One centimeter above the ischial spines
C. Has not entered the pelvic inlet yet
D. Located in the pelvic outlet
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