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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 C

Explanation

A. IM in right deltoid:
The deltoid muscle is not typically used for IM injections in newborns. Additionally, the vastus lateralis muscle in the thigh is preferred over the deltoid muscle for IM injections in infants.

B. Subcutaneous in the right deltoid:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the deltoid muscle is not commonly used for subcutaneous injections in newborns.

C. IM in left vastus lateralis:
This is the correct choice. The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Administering phytonadione via IM injection in the vastus lateralis muscle allows for optimal absorption of the medication.

D. Subcutaneous in the left vastus lateralis:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the vastus lateralis muscle is typically used for IM injections rather than subcutaneous injections in infants.

A. Previous cervical cerclage B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb) C. Previous reactive non-stress test D. Previous delivery at 37 weeks gestation

Correct Answer is A

Explanation

A. Previous cervical cerclage:

Cervical cerclage is a surgical procedure performed to reinforce the cervix in women with a history of cervical insufficiency or cervical incompetence. Cervical insufficiency is a condition where the cervix begins to dilate prematurely, leading to an increased risk of preterm birth. By placing a cervical cerclage, the risk of preterm delivery due to cervical insufficiency is reduced. Therefore, a history of previous cervical cerclage indicates an increased risk for preterm delivery in subsequent pregnancies.

B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb):

A newborn weighing 2.5 kg (5.5 lb) at birth suggests that the infant was small for gestational age (SGA). While SGA infants may be at risk for various complications, such as intrauterine growth restriction (IUGR), it does not directly indicate an increased risk for preterm delivery in subsequent pregnancies. Therefore, this choice is not indicative of preterm delivery risk.

C. Previous reactive non-stress test:

A reactive non-stress test (NST) is a reassuring finding during pregnancy and indicates that the fetus is receiving adequate oxygenation and is not under distress. While the absence of a reactive NST might indicate fetal compromise and the need for further evaluation, a previous reactive NST does not necessarily indicate an increased risk for preterm delivery.

D. Previous delivery at 37 weeks gestation:

A delivery at 37 weeks gestation is considered full-term and does not indicate an increased risk for preterm delivery. In fact, delivering at 37 weeks is within the normal range of gestational age and is not typically associated with preterm birth risk factors. Therefore, this choice does not indicate an increased risk for preterm delivery.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

Correct Answer is C

Explanation

A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

Correct Answer is A

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?

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A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

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