A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation.
Which of the following actions should the nurse take?
Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
Measure the fundal height to determine the placement of the ultrasound stethoscope.
Place the client in a side-lying position prior to assessing the fetal heart rate.
Perform Leopold maneuvers prior to auscultating the fetal heart rate.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
- Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
- Pulse rate: 100 to 160/min
- Respiratory rate: 30 to 60/min
- Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
- Fluid intake: 100 to 150 mL/kg/day
- Fluid output: 1 to 2 mL/kg/hr
Correct Answer is D
Explanation
This prescription is complete because it includes the medication name, dose, route, and frequency.
A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.
Choice A is wrong because it does not specify the dose of cimetidine.
PO twice daily is not enough information to administer the medication safely.
Choice B is wrong because it does not specify the frequency of tetracycline.
200 mg PO is not enough information to administer the medication safely.
Choice C is wrong because it does not specify the route of epoetin alfa.
150 units/kg three times weekly is not enough information to administer the medication safely.
Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.
Normal ranges for cimetidine are 50 to 150 ng/mL.
Normal ranges for tetracycline are 1 to 10 mcg/mL.
Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.
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