Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client?
1. A gravida with intrauterine growth restriction
2. A gravida with mild hypertension of pregnancy
3. A gravida who is post-term
4. A gravida who complains of decreased fetal movement for two days
2
Rationale:
1. The infant who has intrauterine growth problems might be compromised due to placental insufficiency.
2. The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypertension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile.
3. The infant who is post-term might be compromised due to placental insufficiency.
4. The gravida who is experiencing decreased fetal movement for two days needs assessment of the placenta and the fetus.
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The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding would the nurse expect to observe?
a. The leg flexes when the patellar tendon is struck. b. The leg extends when the patellar tendon is struck. c. Toes curl downward when the sole of the foot is stroked. d. The big toe extends when the sole of the foot is stroked.
A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN). Which situation indicates the nurse needs more instruction on delegation?
a. LPN to change a sterile dressing b. NAP to provide skin care c. NAP to insert an indwelling catheter d. LPN to administer an enema
A patient has been admitted to the ICU after being recently diagnosed with an aneurysm. Admission orders include aneurysm precautions. What aneurysm precaution will the nurse incorporate into the patient's plan of care?
A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.
When the nurse's assessment reveals an area of erythema on a patient's sacrum, the first step should be to:
1. apply a wet-to-dry dressing. 2. massage the reddened area. 3. position the patient so that there is no pressure on the sacrum. 4. rub the area with alcohol.