A nurse in a provider's office is assessing a client who is at 28 weeks of gestation. Which of the following is an expected finding?

FHR 152/min via Doppler stethoscope

Client reports the absence of fetal movement for the past 8 hr

Client reports cramping and pelvic pressure

Patellar deep tendon reflex 4+

Answer and Explanation

The Correct Answer is A

Choice A reason: A fetal heart rate of 152/min at 28 weeks gestation is within the normal range of 110–160 beats per minute. This is an expected finding and indicates adequate fetal oxygenation and well-being.

Choice B reason: Absence of fetal movement for 8 hours is concerning and not expected. At 28 weeks, fetal movement should be felt regularly. Lack of movement may indicate fetal distress or compromise and requires immediate evaluation.

Choice C reason: Cramping and pelvic pressure at 28 weeks may indicate preterm labor. These are not expected findings and should be promptly reported and assessed to prevent complications.

Choice D reason: A patellar reflex of 4+ indicates hyperreflexia, which is abnormal and may suggest preeclampsia or other neurologic complications. Normal reflexes are 2+. Therefore, this is not an expected finding.

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Correct Answer is A

Explanation

Choice A reason: Prolonged uterine contractions lasting 90 seconds indicate uterine tachysystole, a dangerous adverse effect of oxytocin. This can reduce placental perfusion, compromise fetal oxygenation, and increase risk of uterine rupture. Immediate intervention is required.

Choice B reason: Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.

Choice C reason: Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.

Choice D reason: A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.

A. Suction the client's endotracheal tube every hr. B. Keep the head of the client's bed flat. C. Turn the client every 4 hr. D. Perform oral care with chlorhexidine.

Correct Answer is D

Explanation

Choice A reason: Suctioning the endotracheal tube every hour is not recommended as a routine preventive measure. Frequent suctioning can cause mucosal trauma, increase the risk of infection, and lead to hypoxemia. Suctioning should be performed only when clinically indicated, such as when secretions are audible or oxygen saturation decreases. Therefore, this option is incorrect because it does not align with evidence-based practices for preventing ventilator-associated pneumonia.

Choice B reason: Keeping the head of the bed flat increases the risk of aspiration of gastric contents and oral secretions, which can lead to ventilator-associated pneumonia. The recommended practice is to elevate the head of the bed to 30–45 degrees to reduce aspiration risk. Thus, this option is incorrect because it promotes conditions that increase infection risk rather than prevent it.

Choice C reason: Turning the client every 4 hours is important for preventing complications such as pressure injuries and improving overall circulation, but it is not a primary intervention for preventing ventilator-associated pneumonia. While repositioning can help mobilize secretions, it is not considered a direct evidence-based measure for reducing pneumonia risk. Therefore, this option is supportive but not the best answer.

Choice D reason: Performing oral care with chlorhexidine is a proven intervention to reduce bacterial colonization in the oropharynx, which is a major source of pathogens that cause ventilator-associated pneumonia. Chlorhexidine oral care decreases microbial load and lowers the incidence of pneumonia in mechanically ventilated patients. This is the correct answer because it directly addresses the prevention of ventilator-associated pneumonia through targeted infection control.

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A nurse in a provider's office is assessing a client who is at 28 weeks of gestation. Which of the following is an expected finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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