A nurse in an antepartum unit is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.

Purulent amniotic fluid

Elevated uric acid level

Fever

Decreased platelet count

Blurred vision

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Findings Consistent with Chorioamnionitis:

Purulent amniotic fluid
Fever

Findings Consistent with Preeclampsia:

Elevated uric acid level
Decreased platelet count
Blurred vision

Rationale:

Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm B. A client who had a right hemisphere stroke C. A client who has a right peripherally inserted central catheter D. A client who had blood drawn from the right antecubital area 1 hr ago

Correct Answer is C

Explanation

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. This is incorrect because the arteriovenous shunt is in the lower forearm, not the upper arm where blood pressure is measured. The right arm can still be used.
B. A client who had a right hemisphere stroke. This is incorrect because a stroke does not necessarily contraindicate blood pressure measurement on the affected side unless there are complications such as edema or weakness.
C. A client who has a right peripherally inserted central catheter. This is correct because taking a blood pressure on the same side as a peripherally inserted central catheter (PICC) can cause pressure that may damage the catheter or affect its function. The left arm should be used instead.
D. A client who had blood drawn from the right antecubital area 1 hr ago. This is incorrect because drawing blood from an arm does not contraindicate blood pressure measurement in that arm after a short period.

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A nurse in an antepartum unit is caring for a client. Exhibits For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is C

Explanation

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A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

A nurse in an antepartum unit is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.