Answer to Question 1
3, 4, 6
Rationale: Fibrinogen is produced by the liver and is necessary for normal clotting. The client who has insufficient levels is at risk for bleeding. The prothrombin time is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. Provide the client with a soft toothbrush, instruct the client to use an electric razor, and monitor all secretions for frank or occult blood are measures that provide for client safety and monitor for bleeding.
Answer to Question 2
1, 2, 3
Rationale: The vaginal examination for a client in labor specifically determines effacement 0 to 100, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to + 5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.
Test-Taking Skills: Knowledge of the vaginal exam and what the nurse will be checking when she performs this assessment is vital to answer this question. Noting the strategic word specifi-cally will direct you to the correct options. If you had difficulty with this question, review the findings of a vaginal examination.
Client on IV patient-controlled analgesia (PCA).
To increase pressure using body weight, lean on your client.
Testing client’s ability to identify sharp sensations
Testing the client’s ability to feel vibrations, the knee
Palpating the liver
Differences in yield between two wheat varieties at different soil fertility levels