A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

The client started working in a parking garage 3 months ago.

The client is doing 30 min of moderate exercise daily.

The client is drinking 2.5 L of water per day.

The client last visited the dentist 4 months ago

Answer and Explanation

The Correct Answer is A

Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.

B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.

C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.

D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.

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Correct Answer is D

Explanation

Rationale:
A. WBC count: A WBC of 13,000/mm³ is within the expected range for pregnancy, as mild leukocytosis commonly occurs due to physiologic changes, and does not require immediate reporting.

B. Fundal height: A fundal height of 27 cm at 29 weeks is slightly below average but may reflect individual variation, fetal position, or maternal factors. This finding warrants monitoring but is not an urgent concern.

C. Fetal heart rate: FHR of 158/min is within the normal range (110–160/min) for a fetus and does not indicate fetal distress, so immediate reporting is not necessary.

D. Hemoglobin: Hemoglobin of 10 g/dL is below the expected range for pregnancy (typically 11–16 g/dL). This indicates anemia, which can affect maternal and fetal oxygenation, making it important to report to the provider for further evaluation and management.

A. A client who has dementia and is incontinent of urine B. A client who has had a recent myocardial infarction C. A client who has a T-tube following an open cholecystectomy D. A client who is 2 days postoperative following orthopedic surgery

Correct Answer is A

Explanation

Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.

B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.

C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.

D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.

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A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

Correct Answer is A

Explanation

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