A nurse is assessing a newborn’s hips using the Ortolani maneuver. Which action correctly demonstrates this technique?

The nurse begins auscultating bowel sounds in a client with no prior abdominal surgery. Where should the nurse begin?

To properly assess the Moro reflex, the nurse should:

A nurse prepares to assess the patellar deep tendon reflex in an adult client. Which action demonstrates correct technique?

During abdominal percussion of a client with mild constipation, the nurse notes: Predominanttympany in the RLQ Localizeddullness in the LLQ The client denies pain, fever, or acute symptoms. Which interpretation is most accurate?

Case Scenario:  A nurse is caring for Mr. Reynolds, a 72-year-old client admitted with pneumonia and dehydration. During the assessment, the student obtains: Temperature: 38.1°C (100.6°F) Heart rate: 112 beats/min Respiratory rate: 24 breaths/min Blood pressure: 92/58 mm Hg Oxygen saturation: 91% on room air The client is awake, alert, and oriented ×4; skin is warm and slightly dry; and reports, “I feel weak and a little short of breath when I move.” The provider has prescribed oxygen PRN for SpO₂ < 92% and IV fluids at 75 mL/hr. Which finding should the nursing student identify as the highest priority?

A client presents for prenatal care. She reports the following history: One full-term vaginal delivery at 39 weeks (child alive) One preterm delivery at 34 weeks (child alive) One spontaneous miscarriage at 10 weeks Currently pregnant What is the correct GTPAL documentation?

The nurse is caring for a 65-year-old client hospitalized with acute heart failure. The nursing care plan includes a goal that “the client’s oxygen saturation will remain above 94% on room air within 48 hours.” After 48 hours, the nurse assesses the client and finds the oxygen saturation is 92% on room air, but the client reports feeling “much less short of breath” and has clear lung sounds upon auscultation. How should the nurse document the status of the goal and determine the next logical step in the nursing process?

A nurse is assessing the radial pulse of an adult client during a routine cardiovascular examination. The nurse aims to obtain an accurate evaluation of pulse characteristics while avoiding common assessment errors that may alter findings. Proper technique is essential to ensure reliable measurement of perfusion and cardiac rhythm. Which action by the nurse demonstrates correct radial pulse assessment technique?

The nurse auscultates a low-pitched extra sound immediately after S2 in a 68-year-old client with dyspnea and peripheral edema. What is the most accurate interpretation?