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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage the client to apply a warm pack to the perineum for discomfort.
While warm packs can provide comfort and promote relaxation for some types of perineal discomfort, they may not be suitable for a third-degree perineal laceration. In fact, applying heat directly to the perineum may exacerbate swelling and increase discomfort in this particular case. Therefore, it is not the most appropriate intervention for this client.
B. Prepare the client for a pudendal nerve block.
A pudendal nerve block is typically used during labor or for specific procedures (such as episiotomy repair) to provide pain relief. It is not a routine intervention for postpartum perineal lacerations.
C. Apply hydrogel pads to the perineum every 4 hr.
While hydrogel pads can provide some relief for perineal discomfort, they are not typically used specifically for third-degree perineal lacerations. These types of lacerations require medical intervention and repair rather than solely relying on over-the-counter remedies like hydrogel pads. Therefore, this intervention may not address the underlying issue effectively.
D. Place a witch hazel pad on the client's perineal pad after each voiding.
Witch hazel pads can provide soothing relief to the perineum and help reduce swelling and discomfort after childbirth. They have a cooling effect and can also have mild astringent properties, which may aid in promoting healing.Placing a witch hazel pad on the perineal pad after each voiding helps ensure that the perineum remains clean and that the client experiences continuous relief from discomfort
Correct Answer is B
Explanation
a.This may help with incision pain or swelling but does not address the ongoing vaginal bleeding.
b.Administering a bolus of lactated Ringer's solution helps to restore fluid volume and maintain blood pressure, which is crucial in managing persistent vaginal bleeding. This action addresses the immediate concern of fluid loss and helps stabilize the patient while further assessments and interventions can be made.
c.While important for monitoring the incision, it does not address the immediate issue of ongoing vaginal bleeding.
d.Important to monitor, but not the first priority in the context of ongoing bleeding. This can be assessed after addressing the bleeding issue.
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