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 D

Explanation

A. Provide clean, dry underpads: While providing clean, dry underpads is important for maintaining cleanliness and comfort for the client, it is not the priority action following an amniotomy. The priority is to assess the fetal well-being by monitoring the fetal heart rate.

B. Assess the odor of the amniotic fluid: Assessing the odor of the amniotic fluid is important for detecting signs of infection; however, it is not the immediate priority following an amniotomy. The primary concern is to assess the fetal response to the procedure by monitoring the fetal heart rate.

C. Monitor the client's temperature: Monitoring the client's temperature is essential for detecting signs of infection, but it is not the priority immediately after an amniotomy. The immediate priority is to assess the fetal well-being by monitoring the fetal heart rate.

D. Assess the fetal heart rate: Following an amniotomy, the priority action by the nurse is to assess the fetal heart rate. Amniotomy involves the artificial rupture of the amniotic sac, which can potentially affect the fetal well-being. Monitoring the fetal heart rate immediately after the procedure allows the nurse to detect any signs of fetal distress and take appropriate actions if necessary.

A. The posterior fontanel is palpable. B. The lowermost portion of the fetus is at the level of the ischial spines. C. The fetal head is in the left occiput posterior position. D. The largest fetal diameter has passed through the pelvic outlet.

Correct Answer is B

Explanation

A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.

B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.

C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.

D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.

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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 in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is D

Explanation

nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct Interpretation of this clinical finding?

Correct Answer is B

Explanation

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