29. A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

Nurses' Notes

0900:

Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
1000:

Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale, Reports feeling dizzy when they got up from examination table
Which of the following findings should the nurse report to the provider?

(Select all that apply.)

Cerebral manifestations

Gastrointestinal assessment findings

Respiratory rate

Deep tendon reflexes

Blood pressure

Feral heart rate

Answer and Explanation

Correct Answer : A,B,C,E,F

A The client reports a mild headache initially but then experiences a more severe headache along with dizziness. These symptoms could preeclampsia or gestational hypertension.
B. The client's presentations increase suspicion for preeclampsia which can lead to liver injury with right upper quadrant tenderness.

C.   It is important to assess the respiratory rate as part of the overall evaluation of the client's condition considering the potential involvement of conditions like preeclampsia, which can affect multiple body systems.

E.   The client's symptoms, including headache, dizziness, and inability to remove rings due to swelling, raise concerns for preeclampsia or gestational hypertension.
F.   Monitoring fetal well-being is essential in the assessment of maternal conditions such as preeclampsia. If there are any concerns about fetal well-being, they should be reported to the provider.

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Correct Answer is C

Explanation

This action is important as it helps to prevent hypothermia, which newborns are particularly susceptible to. However, while drying the infant is essential, it should not be the very first action taken immediately after birth.

Stimulating the infant to cry can help establish normal respiratory function and is important for transitioning to extrauterine life. However, it may not be the first action if the infant is not breathing or appears to need immediate airway clearance.

This is a critical first step, especially if the newborn is not breathing adequately. Clearing the airway (using suction if necessary) is vital to ensure that the infant can breathe properly and transition well after birth. If there are any signs of airway obstruction or if the infant is not crying, this action takes precedence.

While cutting the umbilical cord is a standard procedure, it is typically performed after ensuring the infant is stable. Current guidelines suggest delaying cord clamping for a short period unless there are complications that require immediate action.

A. "If you want me to, I can tell your parents for you." B. "You seem scared to talk to your parents." C. "Your parents will have to be told why you are being admitted." D. "Give your parents a chance; they'll understand."

Correct Answer is B

Explanation

A. This response does not respect the client's autonomy and right to confidentiality.

B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?