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

Explanation

Hydrocephalus is a condition characterized by the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. Manifestations of hydrocephalus in a newborn may include dilated scalp veins, sunset eyes, head enlargement and sutural diastasis due to increased intracranial pressure.

A. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding B. A client who has missed a period and reports vaginal spotting C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who is at 38 weeks of gestation and reports a cough and fever

Correct Answer is A

Explanation

Painless vaginal bleeding in the third trimester could be a sign of placenta previa or placental abruption, both of which are serious conditions requiring immediate medical attention. This client should be seen first due to the potential urgency of the situation.
B. Vaginal spotting in early pregnancy may indicate implantation bleeding or other benign causes, but it could also be a sign of threatened miscarriage or ectopic pregnancy. While this client needs assessment, it's not as urgent as antepartum hemorrhage.
C. A client who is at 14 weeks of gestation and reports nausea and vomiting:

Nausea and vomiting are common symptoms in early pregnancy and typically do not require urgent intervention unless severe dehydration or hyperemesis gravidarum is present.
D. A cough and fever in late pregnancy may indicate a respiratory infection or another illness, but it does not pose an immediate threat to maternal or fetal health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Correct Answer is B

Explanation

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Correct Answer is A

Explanation

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 newborn. Exhibits Complete the diagram by specifying: The potential condition the newborn is most likely experiencing. Two actions the nurse should take to address that condition. Two parameters the nurse should monitor to assess the newborn's progress.

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 is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

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 planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?