A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following?

Decreased heart rate

Increased respirations

Increased temperature

Decreased exhaled carbon dioxide

Answer and Explanation

The Correct Answer is A

A. Decreased heart rate: Bearing down (Valsalva maneuver) can stimulate the vagus nerve, leading to a decrease in heart rate.

B. Increased respirations: Respirations may not increase during the Valsalva maneuver but rather may temporarily decrease or become irregular.

C. Increased temperature: No direct link exists between the Valsalva maneuver and temperature changes.

D. Decreased exhaled carbon dioxide: Valsalva may lead to transient changes in exhaled CO2, but decreased heart rate is the more immediate concern.

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Correct Answer is D

Explanation

A. Vitamin D is essential for bone health, but it does not reduce birth defects.
B. Omega-3 fatty acids support fetal brain development.
C. Lutein supports eye health but is not related to birth defects.
D. Folic acid reduces the risk of neural tube defects and is recommended for women during pregnancy.

A. Warm the enema solution to room temperature. B. Use sterile technique C. Place the client into a right lateral position. D. Lubricate the tubing with an oil-based lubricant.

Correct Answer is A

Explanation

A. Warm the enema solution to prevent discomfort and potential injury from a cold solution.

B. Clean technique is used when administering enemas, not sterile technique.

C. The left lateral position is preferred for enema administration.

D. An oil-based lubricant is not recommended for enema tubing; a water-based lubricant is preferred.

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A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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