The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Magnesium sulfate 4gm (25%) IV
Brethine 10 mcg IV
Stadol 1 mg IV push every 4 hours as needed prn for pain
Ancef 2gm IVPB every 6 hours
The infant is at low risk for congenital anomalies.
The infant is at high risk for intrauterine growth retardation.
The infant is at high risk for respiratory distress syndrome.
The infant is at high risk for birth trauma.
Decreased urinary output
Absence of knee jerk reflex
Decreased respiratory rate
Place her in Trendelenburg position
Decrease the rate of IV infusion
Administer oxygen per nasal cannula
Increase the rate of the IV infusion
Alteration in nutrition
Alteration in bowel elimination
Alteration in skin integrity
Ineffective individual coping
Inspection of the abdomen for enlargement
Bimanual palpation for hepatomegaly
Daily measurement of abdominal girth
Assessment for a fluid wave
Alteration in cerebral tissue perfusion
Fluid volume deficit
Ineffective airway clearance
Alteration in sensory perception
Likes to play football
Drinks several carbonated drinks per day
Has two sisters with sickle cell tract
Is taking acetaminophen to control pain