A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

The weights apply a pulling force continuously.

The boot allows active leg movement.

The footplate rests against the foot of the bed.

The weights are just touching the floor.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.

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Correct Answer is D

Explanation

Rationale:

A. "Store ready-to-feed formula at room temperature for up to 4 hours.": Ready-to-feed formula should be used promptly or refrigerated if not used immediately. Leaving it at room temperature for up to 4 hours increases the risk of bacterial growth and contamination.

B. "Warm the bottle of formula by immersing it in a container of warm tap water.": This is a safe and recommended method to gently warm formula without overheating or creating hot spots that could burn the infant’s mouth.

C. "Keep open cans of concentrated formula uncovered and refrigerated.": Open cans of concentrated formula should always be covered to prevent contamination and should be refrigerated promptly after opening.

D. "Discard any formula left in the bottle within 2 hours after beginning feeding.": Formula left in the bottle after feeding should be discarded within 1 to 2 hours to prevent bacterial growth that can cause illness in the infant. This practice helps ensure feeding safety.

A. Monitor fetal heart rate B. Assist with administration of ampicillin IV. C. Request a prescription for ephedrine. D. Place the client in left lateral position. E. Decrease the IV flow rate.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Rationale:

• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.

• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.

• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.

• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.

• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.

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A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a caregiver about how to safely prepare formula for their 3-day-old newborn. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is in active labor. Exhibits The nurse is assisting with the care of the client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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