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ANS: Squatting using a birth ball, Counter pressure to the sacral area, & leaning forward while kneeling.56.Sitting and leaning forward using both hands for support is an expected finding for a 7-month old infant.57.Type 1 DM, patient indicates understanding of patient teaching when he/she states that, “I will dispose of my needles in a plastic laundry detergent container”.-It is puncture-proof!
58.Offer client a whole grain cracker before bedtime if they are having difficulty sleeping.59.Red meat = iron60.Peanut butter = protein61.External rotation is a clinical manifestation to expect to a client with hip fx62.“Let’s give the medication to your doll first” is an action the nurse should take prior to performing an immunization to a preschooler.63.Dark green and viscous is the stool to expect 24 hrs after birth of an infant.64.Atorvastatin A/E: Muscle Pain65.Suggest walking outside with a staff member to a patient with bipolar disorder & in a manic phase.66.An infection with gonorrhea may result to infertility. STI pt teaching67.Physical neglect indication when collecting a from a toddler is when “the toddler is inadequately dressed for the weather”68.Overdose digoxin? Check VS69.Anorexia Nervosa care plan? Record I&O70.Documenting client care in the medical record, entries to include would be “Client remains NPO until X-Ray procedure is complete”71.To initiate Babinski reflex? Stroke the sole of the infant’s foot upward & toward the great toe.72.Report an ECG result with PR interval 0.24 seconds.73.When patient report of nuchal rigidity, H/A, along with fever & chills. The nurse should anticipate the MD to order what diagnostic tests?74.Post-Op Lumbar puncture: Instruct patient to increase fluid intake.75.The client must take montelukast once daily at bedtime.76.Perform daily gum massage when taking phenytoin as a measure to assist with the possible A/E.77.Lung sound: Wheezes78.Morphine A/E: Respiratory Rate of 10/min79.Document findings as a variance80.pH 7.5 is a complication of mechanical ventilation81.Recent confirmation of pregnancies82.Spaghetti with red meat sauce83.Urine specific gravity of 1.002 for pt with DIATI comprehensive:1.4hr postpartum, boggy uterus with heavy lochia. Which of the following actions should the nurse take?Massage the uterus to expel clotsRationale: ABC approach, priority is to massage uterus to expel clots and increase uterine firmness, resulting in decreased bleeding2.Deficit in Cranial nerve 2: results in visual impairment and lead to fallsclear objects from the walking area3.indicate the progression of labor and are a benign finding -nurse should continue to monitor FHR4.Review ABGs5.A nurse is interviewing a client who has just lost her home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?