A client at 28-weeks gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32.3% (0.323 volume fraction), tells the nurse that she eats plenty of green vegetables.
When the client asks the nurse how the pregnancy might affect the laboratory findings, which information should the nurse provide?

Increasing intake of protein might improve these values.

Plasma volume increases, making the blood count appear low.

Almost all women at 28-weeks gestation have anemia.

It might be necessary to take an iron supplement twice daily.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While protein is an essential nutrient for overall health and wellbeing, increasing protein intake alone is unlikely to significantly improve hemoglobin levels. Hemoglobin is a protein in red blood cells that carries oxygen, and its production depends on having enough iron, vitamin B12, and folic acid, not just protein.
Choice B rationale
During pregnancy, the volume of blood in a woman’s body increases to support the growing fetus. This increase in blood volume can dilute the blood, which can lead to a decrease in the concentration of red blood cells and hemoglobin, a condition known as physiological anemia of pregnancy. This is a normal part of pregnancy and is typically not a cause for concern.
Choice C rationale
While it’s true that many women experience changes in their hemoglobin levels during pregnancy, it’s not accurate to say that almost all women at 28-weeks gestation have anemia. Anemia is defined as a level of hemoglobin that’s lower than normal, and the normal range can vary. However, it’s important to note that the normal range for hemoglobin does decrease during pregnancy.
Choice D rationale
Iron is a key component of hemoglobin, and iron deficiency is a common cause of anemia. If a pregnant woman’s hemoglobin levels are low, taking an iron supplement might help increase these levels. However, it’s important to talk to a healthcare provider before starting any new medication or supplement.

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Correct Answer is B

Explanation

Choice A rationale

While assessing the station of the presenting part is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.

Choice B rationale

Monitoring maternal blood pressure is the most important assessment following the administration of epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.

Choice C rationale

Although assessing the variability of the fetal heart rate is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.

Choice D rationale

While assessing the level of pain sensation is important to evaluate the effectiveness of the epidural anesthesia, it is not the most crucial assessment following its administration.

A. Place a pulse oximeter on the heel B. Swaddle the infant in a warm blanket C. Document the findings in the record D. Obtain a heel stick blood glucose level

Correct Answer is D

Explanation

Choice A rationale
Placing a pulse oximeter on the heel of a newborn can help monitor oxygen saturation levels. However, the symptoms described, such as jitteriness, hypotonicity, and a weak cry, are more indicative of hypoglycemia, a condition that would not be detected by a pulse oximeter.
Choice B rationale
Swaddling the infant in a warm blanket can help maintain body temperature, but it does not address the underlying cause of the symptoms, which are suggestive of hypoglycemia.
Choice C rationale
Documenting the findings in the record is an important part of nursing care, but it does not provide immediate intervention for the symptoms observed.
Choice D rationale
Obtaining a heel stick blood glucose level is the appropriate action given the symptoms described. Jitteriness, hypotonicity, and a weak cry can be signs of neonatal hypoglycemia. Prompt diagnosis and treatment are essential to prevent potential complications.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia. What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is D

Explanation

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution. How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

The nurse is educating parents on how to prevent recurrent otitis media in their infant. What advice should the nurse give?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. What action should the nurse take?

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD. Which statement(s) made by the caregiver demonstrates an understanding?

The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot. What is the most important action for the nurse to perform?

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?