What symptom assessed in the newborn shortly after delivery should be reported?
a. Cyanosis of the hands and feet
b. Irregular heart rate
c. Mucus draining from the nose
d. Sternal or chest retractions
ANS: D
Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
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A patient is taking androgens and warfarin (Coumadin). What effect will these two medications have on the patient's coagulation?
A) Coagulation will be increased. B) Coagulation will be decreased. C) Coagulation will not be affected. D) The RBC will be decreased.
The nurse notes that a client who has been a resident at a rehabilitation facility for 4 weeks has lost 11 pounds since admission. The client goes to physical therapy twice daily
Interventions that are appropriate for this client to maintain adequate nutrition include: Standard Text: Select all that apply. 1. Mild pain medication prior to mealtime. 2. Assisting the client with positioning for mealtimes. 3. Bringing new foods to the client at mealtimes. 4. Heating the room at mealtimes. 5. Assisting the client to the bathroom prior to mealtimes.
A patient has a water-sealed chest drainage system following thoracic surgery. The nurse should instruct the patient and the family that this drainage system is used to:
A) Maintain positive chest wall pressure B) Monitor pleural fluid C) Provide positive intrathoracic pressure D) Re-expand the lung and remove excess air and fluid
Concerning the third stage of labor, nurses should be aware that:
a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.