A nurse at a provider's office is caring for a client.
Oxygen saturation
Vaginal spotting
Heart rate
Bowel sounds
Respiratory findings
Temperature
Abdominal findings
Menstrual period
Correct Answer : B,G,H
A. Oxygen saturation
Oxygen saturation is within normal range at 97%; no immediate follow-up is needed.
B. Vaginal spotting
In early pregnancy, dark red spotting with pain could indicate ectopic pregnancy or threatened abortion and requires immediate evaluation.
C. Heart rate
HR of 90/min is normal and stable, not a concern at this time.
D. Bowel sounds
Hyperactive bowel sounds are nonspecific and not immediately concerning without additional GI symptoms.
E. Respiratory findings
Lung sounds are only slightly diminished, with normal RR and SpO₂, so not urgent.
F. Temperature
37.3°C is within normal limits and does not require follow-up.
G. Abdominal findings
Right lower quadrant tenderness could indicate ectopic pregnancy, appendicitis, or PID and must be evaluated promptly.
H. Menstrual period
Missed period in combination with positive hCG and abdominal pain raises concern for ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You won't be able to input any data until you reset your password.":
Sharing passwords violates HIPAA and hospital policy. The nurse must reset their own password to maintain system security and accountability.
B. "You can use my password on another terminal, but just this one time.":
Sharing login credentials is a HIPAA violation and compromises data integrity.
C. "If you'd like to give me the data, I can enter it for you.":
Entering data under someone else’s credentials is inaccurate and illegal documentation.
D. "The charge nurse can log on for you and watch you input the data.":
Each nurse must use individual login credentials. Even supervision doesn't justify credential sharing.
Correct Answer is ["B","G","H"]
Explanation
A. Oxygen saturation
Oxygen saturation is within normal range at 97%; no immediate follow-up is needed.
B. Vaginal spotting
In early pregnancy, dark red spotting with pain could indicate ectopic pregnancy or threatened abortion and requires immediate evaluation.
C. Heart rate
HR of 90/min is normal and stable, not a concern at this time.
D. Bowel sounds
Hyperactive bowel sounds are nonspecific and not immediately concerning without additional GI symptoms.
E. Respiratory findings
Lung sounds are only slightly diminished, with normal RR and SpO₂, so not urgent.
F. Temperature
37.3°C is within normal limits and does not require follow-up.
G. Abdominal findings
Right lower quadrant tenderness could indicate ectopic pregnancy, appendicitis, or PID and must be evaluated promptly.
H. Menstrual period
Missed period in combination with positive hCG and abdominal pain raises concern for ectopic pregnancy.
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