A nurse is caring for a 9-year-old child at a clinic.
Vital Signs.
1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.
Respiratory rate 22/min.
BP 100/60 mm Hg. Oxygen saturation is 98% on room air.
Nurses' Notes.
1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.
The parent states that several hours.
ago the child tripped and fell onto the sidewalk while playing.
outside.
The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.
their body.
Assessment.
1000:The child is alert and appears developmentally appropriate for their.
age and well nourished.
Respirations are easy and unlabored.
Abdomen nondistended.
The right forearm and fingers are edematous.
Ecchymotic area.
noted on the outer aspect of the forearm.
Radial pulse +2. Fingers.
slightly cool to the touch.
A child can move fingers and reports a mild.
"tingling" sensation.
The child verbalizes a pain level of 4 on a scale.
of 0 to 10. Abrasion noted on the right knee.
No active bleeding.
Multiple areas of bruising were noted on the lower extremities in various.
stages of healing.
The nurse should determine that the assessment findings are consistent with.
which of the following conditions? For each potential condition, click to specify if the assessment findings are.
consistent with a sprain, a fracture, or dislocation.
Each finding may support this.
more than 1 condition.
Sensation
Edema
Pain level
Ecchymosis
The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.
Correct Answer is B
Explanation
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
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