A nurse examining a prenatal patient recognizes that a lag in ...

[JGIBBSON]

A nurse examining a prenatal patient recognizes that a lag in progression of measurements of fundal height from month to month and week to week could signal:
 
  1. Twin pregnancy.
  2. Intrauterine growth restriction.
  3. Polyhydramnios.
  4. Breech position.

Question 2

The nurse is admitting an 8-year-old Vietnamese child who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit.
 
  The child is stoic and denies pain. An appropriate action by the nurse is which of the following?
  (Select all that apply.)
  1. Use the FLACC scale to determinethe child's pain level.
  2. Tell the child to ring the call bell ifthe leg starts hurting.
  3. Administer pain medication now andcontinue on a regular basis.
  4. Ask the child's parents to notifythe nurse if the child complains of pain.

[cupcake16]

Answer to Question 1

2
Rationale 1: A sudden increase in fundal height could indicate twins or polyhydramnios (excessive amount of amniotic fluid).
Rationale 2: A lag in progression of measurements of fundal height from month to month and week to week could signal intrauterine growth restriction (IUGR).
Rationale 3: A sudden increase in fundal height could indicate twins or polyhydramnios (excessive amount of amniotic fluid).
Rationale 4: Breech position would still have a normal fundal height measurement.

Answer to Question 2

Answer:1,3,4
Rationale:Based on the type of injuries the child has,pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-yearold. The child's stoic expression is likely to be culturally related,and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate,it is not the most appropriate initial action.