The nurse in a health care clinic is instructing a client how to ...

[jc611]

The nurse in a health care clinic is instructing a client how to perform kick counts. Which of the following statements, if made by the client, indicates a need for further education?
 
  1. I should lie on my back to perform the procedure.
  2. I will use a clock or a timer and record the number of movements or kicks.
  3. I should count the fetal movements for 30 to 60 minutes three times a day.
  4. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks.

Question 2

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS).
 
  The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is: 1. Atelectasis and viral infection
  2. Bronchoconstriction and stridor
  3. Collapse of alveoli and decreased compliance
  4. Decreased ciliary action and retained secretions

[onowka]

Answer to Question 1

1

Rationale: In general, a client is advised to count the fetal movements for 30 to 60 minutes three times a day. The client should lie on her side. The client is instructed to place her hands on the largest part of her abdomen and to concentrate on the fetal movements. The client should use a timer or a clock, and should record the number of movements felt during that time.

Answer to Question 2

3

Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become stiff due to decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Viral infection may be one reason a client develops atelectasis. Atelectasis and viral infection, bronchoconstriction and stridor, and decreased ciliary action and retained secretions are incorrect.