The nurse is performing an assessment on an infant whose mother ...

[809779]

The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment?
 
  1. Otoscopic exam of the eardrum
  2. Bowel sounds
  3. Vital signs
  4. Skin assessment

Question 2

A primigravida patient has just arrived in the birthing unit.
 
  What steps would be most important for the nurse to perform to gain an understanding of the physical status of the patient and her fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode.
  2. Auscultate the fetal heart rate between and during contractions.
  3. Palpate contractions and resting uterine tone.
  4. Assess the blood pressure, temperature, respiratory rate, and pulse rate.
  5. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers.

[mohan]

Answer to Question 1

1
Rationale 1: If the infant is fed horizontally, positional otitis media could develop because of milk and nasal mucus blocking the eustachian tube.
Rationale 2: Bowel sounds are not affected by the position of the feeding.
Rationale 3: Vital signs are not affected by the position of the feeding.
Rationale 4: The skin is not affected by the position of the feeding.

Answer to Question 2

2,3
Rationale 1: A fetal scalp electrode can be applied only if membranes have ruptured and the cervix is at least 3 cm dilated, and is indicated for high-risk pregnancies.
Rationale 2: Fetal heart rate auscultation gives information about the physical status of the fetus.
Rationale 3: Contraction palpation provides information about the frequency, duration, and intensity of the contractions.
Rationale 4: Vital signs do not provide information on the well-being of the fetus.
Rationale 5: Neither Leopold's maneuvers nor a vaginal exam provides information on the well-being of the fetus.