When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
When the client has ankle edema.
If the client has an elevated blood pressure.
During admission to labor and delivery.
Within the first trimester of pregnancy.
The Correct Answer is B
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B is correct because initiating a continuous infusion of IV fluids per prescription has highest priority for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. Pyloric stenosis causes projectile vomiting and dehydration, which can lead to metabolic alkalosis and electrolyte imbalance. The infant needs IV fluids to correct these abnormalities and prevent complications.
Choice A is incorrect because marking an outline of the “olive-shaped” mass in the right epigastric area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The “olive-shaped” mass is a palpable sign of pyloric stenosis, but it does not require any intervention before surgery.
Choice C is incorrect because monitoring amount of intake and infant's response to feedings is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The infant may have difficulty feeding due to vomiting and gastric distension, which can worsen their dehydration and malnutrition. The infant may need to be kept NPO (nothing by mouth) before surgery.
Choice D is incorrect because instructing parents regarding care of the incisional area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The incisional area will need proper care after surgery, but this can be taught later when the infant is stable and ready for discharge.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is A, B, C, and D.
Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL.
Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube.
Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status.
Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL.
Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.
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