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A nurse in an obstetrics clinic is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

Heart rate 110/min

Respiratory rate 18/min

Blood pressure 104/66 mm Hg

Temperature 36.6° C (97.9° F)

Oxygen saturation 99% on room air

Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

WBC count 7,500/mm3 (5,000 to 10,000/mm3)

Hgb 10.2 g/dL (11 to 16 g/dL)

Hct 45% (33% to 47%)

Platelets 360,000/mm3 (150,000 to 400,000/mm3)

Sodium 136 mEq/L (136 to 145 mEq/L)

Potassium 3.3 mEq/L (3.5 to 5 mEq/L)

BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

Appearance clear (clear)

Color dark amber (pale yellow amber)

pH 7.9 (4.6 to 8)

Protein 4 mg/dL (0 to 8 mg/dL)

Specific gravity 1.045 (1.005 to 1.03)

Leukocyte esterase negative (negative)

Nitrites none (none)

Heart rate 110/min

Blood pressure 104/66 mm Hg

Hemoglobin 10.2 g/dL

Potassium 3.3 mEq/L

BUN 28 mg/dL

Urine specific gravity 1.045

Decreased skin turgor

WBC count 7,500/mm3

Client reports vomiting several times a day over the last 2 weeks

Color dark amber

Answer and Explanation

The Correct Answer is ["A","C","D","E","F","G","I","J"]

Heart rate 110/min
Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.
Blood pressure 104/66 mm Hg
Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.
Hemoglobin 10.2 g/dL
Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.
Potassium 3.3 mEq/L
Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.
BUN 28 mg/dL
Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.
Urine specific gravity 1.045
Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.
Decreased skin turgor
Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.
WBC count 7,500/mm3
Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.
Client reports vomiting several times a day over the last 2 weeks
Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.
Urine color dark amber
Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

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Correct Answer is ["A","C","D","E","F","G","I","J"]

Explanation

Heart rate 110/min
Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.
Blood pressure 104/66 mm Hg
Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.
Hemoglobin 10.2 g/dL
Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.
Potassium 3.3 mEq/L
Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.
BUN 28 mg/dL
Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.
Urine specific gravity 1.045
Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.
Decreased skin turgor
Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.
WBC count 7,500/mm3
Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.
Client reports vomiting several times a day over the last 2 weeks
Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.
Urine color dark amber
Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

A. Weak cry B. Absent Moro reflex C. Respiratory rate of 30/min D. Poor feeding

Correct Answer is D

Explanation

A. Weak cry

While infants with neonatal abstinence syndrome (NAS) may exhibit irritability and excessive crying, a weak cry specifically is not typically associated with NAS. A weak cry could indicate other issues such as respiratory distress or neurological problems, but it is not a characteristic manifestation of NAS.

B. Absent Moro reflex

The Moro reflex is a normal primitive reflex present in newborns, involving the sudden extension and then flexion of the infant's arms in response to a sensation of falling or a loud noise. While NAS can affect the nervous system, leading to irritability and tremors, it typically does not cause the complete absence of the Moro reflex. Thus, this choice is less likely.

C. Respiratory rate of 30/min

A respiratory rate of 30/min in a newborn is within the normal range. While NAS can sometimes cause respiratory distress, it would typically present as symptoms such as rapid breathing, not necessarily a specific rate like 30/min. Therefore, this choice is not strongly associated with NAS.

D. Poor feeding

Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS). Infants born to mothers who used methadone during pregnancy often experience withdrawal symptoms, including irritability and gastrointestinal issues, which can interfere with their ability to feed effectively. Poor feeding is a hallmark sign of NAS and is frequently observed in affected newborns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","E","F","G","I","J"]

Explanation

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

Correct Answer is D

Explanation

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old. Exhibits Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements Indicates understanding of the teaching?

A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?