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The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?
- A. Fetal descent
- B. Placenta previa
- C. Fetal lie and presentation
- D. Strength of uterine contractions
Correct Answer: C
Rationale: The first maneuver, the fundal grip, determines the contents (size, consistency, shape, and mobility) of the fundus (either the fetal head or breech) and thereby the fetal lie. Fetal descent is determined with the fourth maneuver. Placenta previa is diagnosed by ultrasound and not by palpation. Leopold maneuvers are not performed during a contraction.
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The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).
The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator? Select all that apply.
- A. Audible crackles
- B. Client notably restless
- C. Visible mucus bubbling in the ET tube
- D. Apical pulse rate of 72 beats per minute
- E. Low peak inspiratory pressure on the ventilator
- F. High alarm pressures identified by the ventilator
Correct Answer: A,B,C,F
Rationale: Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high-pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.