While caring for a labor patient, the nurse determines during a vaginal exam that the baby's head has internally rotated. This information is given to the family
The labor support person asks the nurse, "What other position changes will the baby undertake during labor and birth?" How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?
1. Flexion, extension, restitution, external rotation, and expulsion
2. Expulsion, external rotation, and restitution
3. Restitution, flexion, external rotation, and expulsion
4. Extension, restitution, external rotation, and expulsion
Correct Answer: 4
Rationale: The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.
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A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How should the nurse respond?
a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions
The nurse understands the impact of sensory deficits on older adults. Which of the following nursing diagnoses are associated with sensory deficits? (Select all that apply.)
A) Constipation B) Diversional activity deficit C) Impaired social interactions D) Risk of injury E) Stress overload
When assessing a baby born 2 days after the due date, the nurse would recognize the due date was accurate if which of the following findings is present?
a. no flexion of extremities b. pale pink skin with no visible veins and little lanugo c. a soft pinna that stays folded d. eyelids fused