A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Assist the client to a prone position.

Ask the client to empty their bladder.

Instruct the client to douche.

Place the client’s arms over their head.

Answer and Explanation

The Correct Answer is B

Ask the client to empty their bladder.

This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.

Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.

Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.

Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.

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Correct Answer is D

Explanation

Place the newborn on a flat surface and clap hands loudly.

This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.

Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.

This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.

Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.

Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.

A. Blood pressure 170/82 mm Hg. B. Respiratory rate 18/min. C. Pulse rate 48/min. D. Potassium 4 mEq/L.

Correct Answer is C

Explanation

Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.

Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.

Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.

Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.

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A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is D

Explanation

A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Correct Answer is C

Explanation

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