The nurse reviews the neonate's medical record and sees the baby is at 38 weeks' gestation. Which of the following findings would make the nurse question the accuracy of this gestation?
1. Infant sleeps with extremities flexed.
2. Square window of 20 degrees
3. Elbow moves past midline when assessing scarf sign.
4. Breast tissue measures 0.7 cm.
3
Rationale: When assessing scarf sign, the term infant's elbow should not reach the midline, where the term infant has more flexibility. The other findings would be appropriate with a term infant.
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A client is scheduled for an intravenous pyelogram. What should the nurse do to prepare the client for this test?
1. Assess for signs of infection. 2. Assess for allergy to seafood. 3. Assess pulses. 4. Instruct to plan on a 4-hour test.
During the health history of the nervous system, a patient tells the nurse about being diagnosed with grand mal seizures. What should the nurse ask the patient to determine characteristic symptoms of the seizures?
A) "At what age did the seizures begin?" B) "When was the last seizure?" C) "How often do the seizures occur?" D) "What occurs after the seizure?"
In what way can evidence from disciplines other than nursing be helpful?
a. Theory based non-nursing evidence can provide a basis on which to build new evidence. b. Non-nursing evidence supports the use of nursing knowledge obtained by trial and error. c. Clinical decision making can be based on findings from single non-nursing research studies. d. All evidence is equally important to the practice of nursing.
When a nurse is called to be an expert witness in a malpractice court case, the nurse draws on many standards of care. All of the following may be used to establish standards for court cases except:
a. Nurse practice acts b. American Nurses Association (ANA) standards c. Medical practice acts d. Institutional policies and procedures