The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
1. Lanugo mainly gone, little vernix across the body
2. Prominent clitoris, enlarging minora, anus patent
3. Full areola, 5 to 10 mm bud, pinkish-brown in color
4. Skin opaque, cracking at wrists and ankles, no vessels visible
2
Explanation: 2. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris.
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Which of the following clinical situations provides an example of transference?
A) A nurse implements the same interventions with multiple clients despite their personal differences. B) A nurse asks for clarification from a colleague when explaining a coping strategy to a client. C) A client mirrors the nursing student's nervousness and hesitancy during assessment. D) A female client with a history of sexual abuse exhibits a profound mistrust of male caregivers.
A patient who is receiving a final dose of intravenous (IV) cephalosporin begins to complain of pain and irritation at the infusion site. The nurse observes signs of redness at the IV insertion site and along the vein. What is the nurse's priority action?
a. Apply warm packs to the arm, and infuse the medication at a slower rate. b. Continue the infusion while elevating the arm. c. Select an alternate intravenous site and administer the infusion more slowly. d. Request central venous access.
A patient is in the Emergency Department with heat stroke. What finding does the healthcare provider associate with this condition?
a. Core temperatures usually reaching approximately 39.5?C (103.1?F) b. Absence of sweating despite a high core temperature c. A rapidly decreasing core temperature as heat loss from the evaporation of sweat ceases d. Symptoms caused by the loss of sodium and prolonged sweating