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

Exhibits
Select the 2 findings that require immediate follow-up.

Blood pressure

Fetal heart rate

Fetal station

Characteristics of amniotic fluid

Duration of contraction

Answer and Explanation

Correct Answer : B,D

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

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Correct Answer is A

Explanation

A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.

A. "I will take the medication in the morning." B. "I will take the medication on an empty stomach." C. "I will avoid crushing this medication." D. "I will expect to gain weight."

Correct Answer is C

Explanation

A. "I will take the medication in the morning." Metformin extended-release can be taken once daily, but it is usually recommended with the evening meal to improve gastrointestinal tolerance.
B. "I will take the medication on an empty stomach." This is incorrect because metformin should be taken with food to reduce gastrointestinal side effects such as nausea and diarrhea.
C. "I will avoid crushing this medication." This is correct because extended-release tablets should not be crushed, split, or chewed, as this can alter the drug’s release mechanism.
D. "I will expect to gain weight." Metformin is not associated with weight gain; in fact, it may cause modest weight loss in some clients.

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A nurse in an antepartum unit is caring for a client. Exhibits Select the 2 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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

Exhibits
Select the 2 findings that require immediate follow-up.