The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

Observing for mental confusion or hallucinations.

Assessing motor function.

Monitoring for a decrease in spasticity.

Performing a follow-up MRI.

Answer and Explanation

The Correct Answer is C

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

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Correct Answer is B

Explanation

Choice A reason: The statement that "Semi-Fowler's is the safest position for pushing" is not necessarily appropriate because the best position for pushing can vary from one woman to another. There is no single safest position universally recommended for all labouring women. The choice of position should be individualized based on the woman's comfort, progress of Labor, and any specific medical considerations. The Semi-Fowler's position involves lying semi-upright, which might be suitable for some but not for everyone.

Choice B reason: Advising the patient to "choose a position you feel most comfortable" is appropriate because it empowers the woman to listen to her body and adopt a position that feels natural and effective for her. Comfort plays a crucial role in the effectiveness of pushing and the overall Labor experience. This approach promotes a sense of control and autonomy for the labouring woman and aligns with best practices in patient-cantered maternity care.

Choice C reason: Suggesting that "sitting with your head elevated on two pillows makes pushing easier" may not be the best advice for every labouring woman. While this position might work for some, it is not universally effective or recommended. Labor positions should be flexible and adaptive to the individual's needs and comfort. Blanket recommendations can overlook the diversity of experiences and preferences among labouring women.

Choice D reason: Telling the patient that "it is normal if you're having a bowel movement" might address a concern some women have during Labor. However, it does not directly guide the woman on effective pushing positions. While it can be reassuring to mention that a bowel movement can occur during pushing, this statement alone is not sufficient as a primary piece of advice for managing the second stage of Labor.

Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

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The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the second stage of Labor. Which statement by the nurse is appropriate?

Correct Answer is B

Explanation

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

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