lOMoARcPSD 40206794 can perform pin care there is no need to clean the weights therefore answers B C and D are incorrect 146 Answer A is correct A body cast or spica cast extends from the upper abdomen to the knees or below Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus Checking the blood pressure is a treatment for any client offering pain medication is not called for and checking for swelling isn t specific to the stem so answers B C and D are incorrect 147 Answer C is correct Halo traction will be ordered for the client with a cervical fracture Russell s traction is used for bones of the lower extremities as is Buck s traction Cruchfield tongs are used while in the hospital and the client is immobile therefore answers A B and D are incorrect 148 Answer B is correct The controller for the continuous passive motion device should be placed away from the client Many clients complain of pain while having treatments with the CPM so they might turn off the machine The CPM flexes and extends the leg The client is in the bed during CPM therapy so answer A is incorrect Answer C is incorrect because clients will experience pain with the treatment Use of the CPM does not alleviate the need for physical therapy as suggested in answer D 240 Chapter 3 149 Answer A is correct The client s palms should rest lightly on the handles The elbows should be flexed no more than 30 but should not be extended Answer B is incorrect because 0 is not a relaxed angle for the elbows and will not facilitate correct walker use The client should walk to the middle of the walker not to the front of the walker making answer C incorrect The client should be taught not to carry the walker because this would not provide stability thus answer D is incorrect 150 Answer C is correct The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist sterile saline gauze The nurse should use her fingers to push up on the presenting part until a Cesarean section can be performed Answers A B and D are incorrect The nurse should not attempt to replace the cord turn the client on the side or cover with a dry gauze lOMoARcPSD 40206794 151 Answer B is correct Chest tubes work to reinflate the lung and drain serous fluid The tube does not equalize expansion of the lungs Pain is associated with collapse of the lung and insertion of chest tubes is painful so answers A and C are incorrect Answer D is true but this is not the primary rationale for performing chest tube insertion 152 Answer D is correct Success with breastfeeding depends on many factors but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt The educational level the infant s birth weight and the size of the mother s breast have nothing to do with success so answers A B and C are incorrect 153 Answer C is correct Green tinged amniotic fluid is indicative of meconium staining This finding indicates fetal distress The presence of scant bloody discharge is normal as are frequent urination and moderate uterine contractions making answers A B and D incorrect 154 Answer C is correct Duration is measured from the beginning of one contraction to the end of the same contraction Answer A refers to frequency Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction Duration is not measured from the peak of the contraction to the end as stated in answer D 155 Answer B is correct The client receiving Pitocin should be monitored for decelerations There is no association with Pitocin use and hypoglycemia maternal hyperreflexia or fetal movement therefore answers A C and D are incorrect 156 Answer D is correct Fetal development depends on adequate nutrition and insulin regulation Insulin needs increase during the second and third trimesters insulin requirements do not moderate as the pregnancy progresses and elevated human chorionic gonadotrophin elevates insulin needs not decreases them therefore answers A B and C are incorrect 157 Answer A is correct A calm environment is needed to prevent seizure activity Any stimulation can precipitate seizures Obtaining a diet history should be done later and administering an analgesic is not indicated because there is no data in the stem lOMoARcPSD 40206794 to indicate pain Therefore answers B and C are incorrect Assessing the fetal heart tones is important but this is not the highest priority in this situation as stated in answer D Practice Exam 3 and Rationales 241 158 Answer A is correct The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations Answers B C and D are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice and Turner s syndrome is a genetic disorder 159 Answer C is correct The client with a missed abortion will have induction of labor Prostin E is a form of prostaglandin used to soften the cervix Magnesium sulfate is used for preterm labor and preeclampsia calcium gluconate is the antidote for magnesium sulfate and Parlodel is a dopamine receptor stimulant used to treat Parkinson s disease therefore answers A B and D are incorrect Parlodel was used at one time to dry breast milk 160 Answer A is correct The client s blood pressure and urinary output are within normal limits The only alteration from normal is the decreased deep tendon reflexes The nurse should continue to monitor the blood pressure and check the magnesium level The therapeutic level is 4 0 8 0mg dL Answers B C and D are incorrect because there is no need to stop the infusion at this time or slow the rate Calcium gluconate is the antidote for magnesium sulfate but there is no data to indicate toxicity 161 Answer C is correct Autosomal recessive disorders can be passed from the parents to the infant If both parents pass the trait the child will get two abnormal genes and the disease results Parents can also pass the trait to the infant Answer A is incorrect because to have an affected newborn the parents must be carriers Answer B is incorrect because both parents must be carriers Answer D is incorrect because the parents might have affected children 162 Answer D is correct Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida The test is not mandatory as stated in answer A It