A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

"The client was intubated without complications."

"The estimated blood loss was 250 milliliters."

"There was a total of 10 sponges used during the procedure."

"The client is a member of the board of directors."

Answer and Explanation

The Correct Answer is B

A. "The client was intubated without complications.": While this information can be relevant, it is more pertinent to include in the PACU hand-off only if intubation or airway management had ongoing implications. Routine, uncomplicated intubation is less critical than current clinical status and intraoperative events.

B. "The estimated blood loss was 250 milliliters.": Reporting estimated blood loss is essential for continuity of care, as it informs the receiving nurse about the client’s fluid status, potential for anemia, and need for ongoing monitoring or interventions. This is a key safety and clinical detail in the hand-off report.

C. "There was a total of 10 sponges used during the procedure.": While sponge count is important intraoperatively to prevent retained surgical items, it is typically documented in the surgical record and does not usually impact post-anesthesia care unless discrepancies exist.

D. "The client is a member of the board of directors.": Personal information unrelated to the client’s clinical care is not appropriate to include in a hand-off report. The focus should remain on pertinent medical, surgical, and recovery information.

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Correct Answer is C

Explanation

A. Hypertension: Hypertension is not a typical complication of amniocentesis. While it may occur in pregnancy for other reasons, it is not directly related to this procedure and does not require specific post-procedure monitoring in this context.

B. Vomiting: Vomiting is not a common complication following amniocentesis. Nausea or discomfort may occur, but persistent vomiting is not expected and would likely be unrelated to the procedure itself.

C. Contractions: Uterine contractions are a potential complication after amniocentesis, especially in the third trimester. The nurse should monitor for signs of preterm labor, including contractions, cramping, or changes in fetal movement, to intervene promptly if needed.

D. Epigastric pain: Epigastric pain is not commonly associated with amniocentesis. It may indicate other conditions, such as preeclampsia or gastrointestinal issues, but it is not a typical post-procedure complication.

A. Rolls from back to side B. Rolls from back to abdomen C. Sits steadily unsupported D. Changes from prone to sitting

Correct Answer is A,B,C,D

Explanation

A. Rolls from back to side: This is usually the first gross motor milestone among the options, occurring around 4–6 months. It demonstrates early trunk rotation and control of head and shoulder movements.

B. Rolls from back to abdomen: This skill typically develops after rolling from back to side, around 5–6 months. It requires stronger neck and trunk muscles, as well as coordinated limb movement to shift the center of gravity.

C. Sits steadily unsupported: Sitting without support generally occurs between 6–8 months. It reflects significant trunk and abdominal muscle development, allowing the infant to maintain upright posture and balance independently.

D. Changes from prone to sitting: This is a more advanced gross motor skill, usually emerging around 9 months. It requires complex coordination, upper body strength, and balance to transition from lying on the stomach to a seated position

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A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Correct Answer is C

Explanation

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

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