Which client's indications most warrant fetal monitoring in the third trimester?
1. Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks
2. Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy
3. Gravida 3, para 2, with a history of gestational diabetes controlled by diet
4. Gravida 2, para 1, 36 weeks, with hypertension disorder of pregnancy
4
Rationale:
1. The client with the spontaneous abortion would have needed to be monitored in the first trimester.
2. The client with endometriosis and appendectomy would have been a concern with conception.
3. The client with a history of gestational diabetes controlled by diet would need maternal monitoring and fetal monitoring if she developed gestational diabetes again.
4. The preterm client with a pregnancy-associated disorder needs close monitoring for preterm labor onset or the need to induce preterm labor.
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The nurse is documenting the pediatrician's assessment of a female patient. When assessing Tanner's stages of breast development there is elevation of papilla only. What stage of development will the nurse document?
a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
Calculate the daily rate of maintenance fluids and the IV hourly flow rate for a child who weighs 25 kilograms
1. 500 mL per day; 20.8 mL per hour 2. 170 mL per day; 7 mL per hour 3. 600 mL per day; 25 mL per hour 4. 1600 mL per day; 66 mL per hour
During an assessment the nurse observes the client jumping from one idea to another, unable to completely answer any of the assessment questions. The nurse recognizes this speech pattern as being:
1. Circumlocution. 2. Flight of ideas. 3. Neologisms. 4. Echolalia.
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium?
a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.