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NURSING 660 - maternity and obstetric HESI

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Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? Have the client empty her bladder. Correct Request the client lie on her left side. Per... form Leopold’s maneuvers first. Give the client some cold juice to drink. To accurately measure the fundal height, the bladder must be empty (A) to avoid elevation of the uterus. Fundal height is not measured with the client lying on her side (B). Leopold's maneuvers are performed to assess fetal position and the expected location of the point of maximal impulse (PMI) for fetal heart rate (C). Cold juice (D) does not affect the fundal height measurement, but may be given to arouse the fetus if the fetus appears to be sleeping during a non-stress test. Awarded 1.0 points out of 1.0 possible points. 2.ID: 311028927 The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? Elicit a positive scarf sign on the affected side. Observe for an asymmetrical Moro (startle) reflex. Correct Watch for swelling of fingers on the affected side. Note paralysis of affected extremity and muscles. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved. Eliciting (A) (extending arm across the chest toward the opposite shoulder) is contraindicated if a fractured clavicle is present. (C and D) on the affected side require follow-up, but are not indicative of a fractured clavicle. Awarded 1.0 points out of 1.0 possible points. [Show More]

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