When the nurse is performing an admission physical assessment on the pediatric client who is under 30 days old, additional data to note includes:(Select all that apply) Standard Text: Select all that apply
1. Shape of head
2. Presence of barrel-chested appearance
3. Asymmetric gluteal folds
4. Presence of receding gums
5. Excursion symmetry or asymmetry of chest on respiration
1,3
Rationale: The shape of the infants head should only be altered by vaginal delivery for about 1 week; longer than that may need follow up
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The nurse is caring for a woman with a placental abruption and suspects the patient has developed disseminated intravascular coagulation (DIC). What interventions does the nurse anticipate?
A. Administering IV fibrinogen B. Performing hourly vaginal exams to assess for cervical dilation C. Performing blood pressure assessments every 4 hours D. Obtaining consent for a cesarean birth
When interviewing a 68-year-old male client, the nurse discovers a list of 23 herbal and vitamin supplements that are being consumed by the client each day
Which response by the client indicates the need for further nutritional teaching by the nurse at this visit? 1. "I have been taking all of them for over 20 years now." 2. "My doctor in my old town recommended most of them." 3. "My wife also takes the same things." 4. "I know that I do not eat right all of the time, so they will keep me healthy."
The nurse should emphasize that the rehabilitation of the spinal cord–injured patient:
1. usually is achieved within a few months after stabilization. 2. will return the spinal cord–injured patient to the preaccident functional level. 3. focuses on adjustments necessary to reenter society and the workplace. 4. completely targets on self-care.
After receiving her Rho(D) immune globulin a client states, "So this will keep my body from ever rejecting my babies?" What would be the nurse's best response?
a. "This medication will prevent antibody formation now, but it may be necessary again with future pregnancies." b. "Yes, it will give you immunity against Rh-positive blood." c. "You will be given this medication again after every delivery." d. "You will need a titer at your 6 week checkup to see if you have immunity."