A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
Percussion
Auscultation
Palpation
Inspection
The Correct Answer is C
Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: High-osmolarity formulas may cause diarrhea but are not directly linked to aspiration risk. Aspiration results from improper positioning or reflux, not formula osmolarity, so this factor is less relevant, making it incorrect for identifying aspiration risk in enteral feedings.
Choice B reason: Sitting in high-Fowler’s position (60-90 degrees) reduces aspiration risk by promoting gastric emptying and preventing reflux during enteral feedings. This is a protective measure, not a risk factor, making it incorrect for this scenario.
Choice C reason: A residual of 65 mL 1 hour postprandial is within acceptable limits (<100-200 mL, per facility protocol) and does not indicate high aspiration risk. Elevated residuals may suggest delayed emptying, but this value is normal, making it incorrect.
Choice D reason: A history of gastroesophageal reflux disease increases aspiration risk, as reflux can allow gastric contents to enter the airway during enteral feedings. This condition compromises esophageal sphincter function, making it a significant risk factor and the correct choice.
Correct Answer is C
Explanation
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A. Maternal fever Maternal fever typically causes fetal tachycardia (elevated baseline >160/min), not bradycardia. Fever increases maternal metabolic rate and fetal heart rate.
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B. Chorioamnionitis This intrauterine infection also leads to fetal tachycardia, due to inflammatory stress and maternal fever. It is not a cause of bradycardia.
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C. Maternal hypoglycemia ✅ Low maternal glucose levels can reduce fetal energy supply and oxygenation, leading to fetal bradycardia (baseline <110/min). This is a recognized cause of sustained bradycardia.
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D. Fetal anemia Fetal anemia usually results in tachycardia as the fetus compensates for reduced oxygen‑carrying capacity by increasing heart rate. It does not cause bradycardia.
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