51. A nurse in an antepartum clinic is caring for a client who is pregnant.

Medical History 0815:

Gravida 4 Para 3

33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)

BMI 30.6

3.2 kg (7 lb) weight gain over the last 2 weeks

Select the 4 assessment findings the nurse should report to the provider.

Deep tendon reflexes

Visual disturbances

Fetal heart rate

Blood pressure

Weight

Answer and Explanation

Correct Answer : C,D,E

Visual disturbances in a pregnant client could indicate conditions such as preeclampsia or gestational hypertension, which require immediate medical attention.

Monitoring the fetal heart rate is essential to assess fetal well-being, and any abnormalities in the fetal heart rate may require further evaluation by the provider.
Changes in blood pressure, especially elevated blood pressure, may indicate gestational hypertension or preeclampsia, which require monitoring and management by the provider. A significant weight gain of 3.2 kg (7 lb) over the last 2 weeks may indicate fluid retention or other issues that need assessment and intervention by the provider.

Deep tendon reflexes (option A) are not typically assessed routinely in antepartum care unless there are specific indications, such as signs of preeclampsia.

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

Explanation

B. This statement indicates the client understands the importance of monitoring the incision site for any signs of infection, such as discharge, and knows to seek medical attention if these signs occur.
D. This statement indicates the client understands that while some discomfort is normal after a cesarean birth, unrelieved or severe pain could be a sign of complications and should be addressed promptly.
A. Resting in a recliner may not provide adequate support or promote proper healing of the incision site.
C. While continuing prenatal vitamins may be beneficial for overall health, it is not directly related to the cesarean birth recovery process.
E. A fever during the first week at home is not a typical occurrence and may indicate an infection, which should be evaluated by a healthcare provider. Therefore, it is not accurate to expect a fever during this time.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Palpate the client's uterus. D. Administer oxygen to the client. E. Administer oxygen to the client.

Correct Answer is A

Explanation

Late decelerations on the fetal monitor tracing indicate uteroplacental insufficiency, which can compromise fetal oxygenation. When membranes rupture and late decelerations occur, it's essential to take immediate action to improve fetal oxygenation.
Turning the client onto her side can help improve uteroplacental perfusion by relieving pressure on the vena cava and increasing blood flow to the uterus. This is the initial recommended intervention to optimize fetal oxygenation in the presence of late decelerations.
B. Increasing IV fluid infusion rate may be considered to optimize maternal hydration and potentially improve uteroplacental perfusion. However, it may not be the first action taken in response to late decelerations.
C. Palpating the client's uterus can provide information about uterine activity and may help assess for uterine hyperstimulation, which can contribute to fetal distress. However, in the context of late decelerations, the priority is to address potential uteroplacental insufficiency and optimize fetal oxygenation.
D. Administering oxygen to the client helps increase maternal oxygenation, which in turn improves fetal oxygenation. Oxygen administration is done after positing the client on to the lateral position.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

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

Explanation

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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