A nurse at a provider's office is caring for a client.
Select the 3 findings that require immediate follow-up.
Respiratory findings
Menstrual period
Vaginal spotting
Oxygen saturation
Heart rate
Temperature
Bowel sounds
Abdominal findings
Correct Answer : A,C,H
- Respiratory findings: The client has a history of asthma and now presents with slight inspiratory wheezes. Although respiratory rate and oxygen saturation are normal, wheezing indicates airway narrowing, which could worsen rapidly and needs prompt follow-up to prevent an acute asthma exacerbation.
- Menstrual period: The client's menstrual period is late by two weeks, but in itself, a late period does not require immediate intervention. It is an important clinical detail but does not demand urgent follow-up unless accompanied by unstable vital signs or other concerning symptoms.
- Vaginal spotting: Scant dark red spotting in a client with a late menstrual period raises concern for an ectopic pregnancy, which can be life-threatening if it ruptures. Spotting, combined with abdominal tenderness and delayed menses, demands immediate evaluation to rule out ectopic pregnancy or miscarriage.
- Oxygen saturation: The oxygen saturation of 97% on room air is within the normal range for a healthy adult. There is no evidence of hypoxemia, so this finding does not require immediate follow-up despite the client’s mild wheezing.
- Heart rate: The heart rate of 90/min is normal and within expected limits for adults. Although the client appears anxious, the heart rate itself does not indicate hemodynamic instability and does not require immediate intervention.
- Temperature: A temperature of 37.3° C (99.1° F) is within the normal range and does not suggest active infection or systemic illness. There is no immediate concern based solely on the client’s current temperature reading.
- Bowel sounds: Hyperactive bowel sounds can be associated with various conditions, including gastroenteritis, early bowel obstruction, or anxiety. While they contribute to the overall clinical picture of abdominal discomfort, they do not, on their own, necessitate immediate follow-up .
- Abdominal findings: Right lower quadrant abdominal tenderness, especially in combination with spotting and late menses, is concerning for an ectopic pregnancy. The possibility of rupture or hemorrhage makes abdominal tenderness a critical finding that requires urgent evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hyperbilirubinemia: Hyperbilirubinemia in neonates is commonly due to immature liver function and the breakdown of red blood cells after birth. It is not linked to maternal folic acid deficiency and would not be prevented through maternal folic acid supplementation.
B. Hyperemesis gravidarum: Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs during pregnancy, affecting the mother rather than the neonate. Folic acid supplementation does not prevent this condition, as it is more related to hormonal changes during pregnancy.
C. Iron deficiency anemia: Iron deficiency anemia occurs when there is an inadequate amount of iron, not folic acid, in the mother’s or infant’s diet. While iron is important during pregnancy for both the mother and the developing fetus, folic acid deficiency primarily affects neural tube development, not iron levels or red blood cell production in the same way. Iron supplementation is recommended during pregnancy to prevent iron deficiency anemia.
D. Neural tube defects: Neural tube defects, such as spina bifida and anencephaly, are directly linked to folic acid deficiency during early pregnancy. Adequate folic acid intake before conception and during early pregnancy significantly reduces the risk of these serious birth defects affecting the brain and spine.
Correct Answer is B
Explanation
A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.
B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.
C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.
D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.
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