The nurse is assessing the client's muscle strength and notes ...

[luvbio]

The nurse is assessing the client's muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed.
 
  How would the nurse correctly document this finding on the medical record? 1. Client is demonstrating ataxia.
  2. Client is exhibiting pronator drift.
  3. Client examination reveals hyperreflexia.
  4. Client appears to have nystagmus.

Question 2

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. The nurse would prepare the client for:
 
  1. Delivery of the fetus
  2. Strict monitoring of intake and output
  3. Complete bed rest for the remainder of the pregnancy
  4. The need for weekly monitoring of coagulation studies until the time of delivery

[mohan]

Answer to Question 1

2

Rationale: Pronator drift occurs when a client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Hyperreflexia is an excessive reflex action. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications.

Answer to Question 2

1

Rationale: The goal of management in abruptio placentae is to control the hemorrhage and de-liver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining op-tions are incorrect regarding management of the client with abruptio placentae.

[luvbio]

TY

[mohan]

You're welcome