A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Answer and Explanation

The Correct Answer is ["732"]

To calculate the total intake, we need to convert all measurements to the same unit, in this case, milliliters (mL).

1 ounce (oz) is approximately equal to 29.5735 mL.

Also, it’s important to note that when ice chips melt, they become about half their volume in water. So, 100 mL of ice chips would become about 50 mL of wate

Let’s calculate:

Juice: 4 oz * 29.5735 = 118.294 mL

Tea: 6 oz * 29.5735 = 177.441 mL

Ice chips: 100 mL * 0.5 = 50 mL

IV bolus: 150 mL

Broth: 8 oz * 29.5735 = 236.588 mL

Adding all these together:

118.294 mL (juice) + 177.441 mL (tea) + 50 mL (ice chips) + 150 mL (IV bolus) + 236.588 mL (broth) = 732.323 mL

So, the nurse should record 732 mL of intake on the client’s record (rounded to the nearest whole number).

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Correct Answer is A

Explanation

A) Lecithin/sphingomyelin (L/S) ratio of 2:1: An L/S ratio of 2:1 or higher is indicative of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that contribute to the development of the fetal lung surfactant. A higher ratio suggests that the lungs have reached maturity and are capable of adequate gas exchange.
B) Phosphatidylglycerol (PG) absent: The presence of phosphatidylglycerol (PG) in amniotic fluid is a sign of fetal lung maturity. Absence of PG suggests that the fetal lungs may not have reached maturity.
C) Biophysical profile score of 8: The biophysical profile (BPP) is a prenatal ultrasound evaluation of fetal well-being. While a BPP score of 8 out of 10 is reassuring, it does not specifically indicate fetal lung maturity.
D) Nonstress test is reactive: A reactive nonstress test (NST) indicates that the fetal heart rate accelerates appropriately with fetal movement, suggesting fetal well-being. However, it does not provide information about fetal lung maturity.

A. Assist the client to an upright position. B. Prepare for a cesarean birth. C. Assist the client to turn onto her side. D. Prepare for an immediate vaginal delivery.

Correct Answer is C

Explanation

A) Assist the client to an upright position: While changing the client's position can sometimes help improve blood pressure, in this scenario, the blood pressure reading is already low. Placing the client in an upright position may further decrease blood pressure, potentially exacerbating hypotension. Therefore, this option is not the most appropriate choice.
B) Prepare for a cesarean birth: A blood pressure reading of 82/52 mm Hg alone does not necessarily indicate the need for a cesarean birth. Cesarean birth is typically indicated for fetal distress, cephalopelvic disproportion, or other complications, none of which are mentioned in the scenario. Therefore, preparing for a cesarean birth based solely on the blood pressure reading is not indicated at this time.
C) Assist the client to turn onto her side: A blood pressure reading of 82/52 mm Hg suggests hypotension. Turning the client onto her side can help improve venous return to the heart and increase blood pressure by alleviating pressure on the inferior vena cava, thus improving cardiac output. This position change can help optimize blood pressure and perfusion to both the client and the fetus.
D) Prepare for an immediate vaginal delivery: While hypotension can be a concern during labor, particularly in the active phase, the client's blood pressure reading alone does not necessitate an immediate vaginal delivery. The priority is to address the hypotension and ensure adequate perfusion to the client and the fetus. Turning the client onto her side is a more appropriate initial intervention to improve blood pressure.

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A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer is C

Explanation

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