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Author Question: The nurse is measuring an abdominal girth on a child with abdominal distension.Identify the area on ... (Read 111 times)

Frost2351

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The nurse is measuring an abdominal girth on a child with abdominal distension.Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth.
 
  1. Just above the umbilicus,around thelargest circumference of the abdomen
  2. Below the umbilicus
  3. Just below the sternum
  4. Just above the pubic bone

Question 2

A 43-year-old patient has just had a positive pregnancy test. She cries, and states, I just don't know what I'll do. I can't be pregnant. Which nursing diagnosis would be the most appropriate?
 
  1. Decisional Conflict related to unexpected pregnancy
  2. Deficient Knowledge related to advanced maternal age
  3. Depression related to unexpected pregnancy
  4. Ineffective Health Maintenance related to advanced maternal age



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nital

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Answer to Question 1

Answer:1
Rationale: An abdominal girth should be taken around the largest circumference of the abdomen,in this case,just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Answer to Question 2

1
Rationale 1: Decisional Conflict related to unexpected pregnancy is the most appropriate nursing diagnosis. An unplanned pregnancy at any age is often a life-changing event for the patient.
Rationale 2: The woman does not appear to be distressed because of a lack of knowledge. In fact, understanding that women over the age of 35 have a higher incidence of pregnancy complications could be the cause of her distress.
Rationale 3: Depression can occur, but not enough information is given to indicate that this patient is depressed.
Rationale 4: Nothing suggests that the patient is not maintaining her health.





 

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