Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.

Diminished hearing

Pupils

Lung assessment

Facial nerve assessment

Vertigo

Pain rating

Answer and Explanation

Correct Answer : D,E,F

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

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Correct Answer is D

Explanation

A. Weight loss: Fluid overload is characterized by excessive fluid retention rather than loss. Weight gain is a more common finding due to fluid accumulation in tissues. Weight loss would be associated with dehydration, malnutrition, or inadequate caloric intake rather than fluid overload.
B. Decreased blood pressure: Fluid overload typically leads to increased blood pressure due to excess circulating volume. Decreased blood pressure is more commonly seen in dehydration or conditions that result in significant fluid loss, such as hemorrhage or severe diarrhea.
C. Decreased skin turgor: Poor skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, clients may exhibit edema, moist skin, and increased vascular volume instead of signs of dehydration.
D. Crackles heard in the lungs: Crackles in the lungs indicate pulmonary congestion due to excess fluid accumulation, which can occur with fluid overload. Increased intravascular volume leads to leakage of fluid into the alveoli, causing difficulty breathing, shortness of breath, and pulmonary edema in severe cases.

A. Client reports the urge to defecate B. There is increased bloody show C. cervix is 10 cm dilated D. Contractions strong on palpation E. Temperature 39.1° C (102.4" F) F. Heart rate 110/min

Correct Answer is ["A","B","C","D"]

Explanation

Rationale for Correct Options:

Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

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Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.