Tell whether the following statement is true or false. Touch is a personal behavior that means the same thing to all persons.
a. true
b. false
Ans: b. false
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The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal?
a. An axillary temperature of 36.6 ° C (98 ° F) b. An apical pulse rate of 178 beats/min c. Respirations of 35 breaths/min d. Blood pressure of 80/50 mm Hg
A patient tells the nurse at the clinic, "I have been leaving out my midday dose of antidepressant medication. I have lunch with friends and don't want them to know I take pills." Select the nurse's most effective intervention
a. Investigate the possibility of once-daily dosing of the antidepressant. b. Explain how taking each dose of medication on time relates to health maintenance. c. Suggest the patient take the medication when none of the friends is watching. d. Establish the nursing diagnosis, Ineffective management of the therapeutic regimen.
The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring patient who is undergoing a forceps delivery. Which action requires intervention?
1. Regional anesthesia is administered via pudendal block. 2. The patient is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Bladder is emptied using a straight catheter.
The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important?
1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour.