A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

Apply the largest cuff available.

Place the arm above the level of the client's heart.

Deflate the cuff quickly.

Use the palpatory method to determine blood pressure.

Answer and Explanation

The Correct Answer is D

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.

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Correct Answer is A

Explanation

A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.

A. Maintain eye contact with the newborn during feedings. B. Swaddle the newborn with his legs extended. C. Minimize noise in the newborn's environment. D. Administer naloxone to the newborn.

Correct Answer is C

Explanation

A. Incorrect. While maintaining eye contact during feedings is generally beneficial for bonding, it's not a specific intervention for managing neonatal abstinence syndrome.

B. Incorrect. Swaddling a newborn with extended legs might be uncomfortable, as newborns with neonatal abstinence syndrome can experience increased muscle tone and jitteriness.
C. Correct. Newborns with neonatal abstinence syndrome can be hypersensitive to stimuli, including noise. Minimizing noise in the environment helps reduce stress and overstimulation.
D. Incorrect. Naloxone is not typically administered to newborns with neonatal abstinence syndrome. The syndrome is managed through supportive care, gradually reducing exposure to the substance.

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A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

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