A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation
Select the 5 findings that require follow up by the nurse
Nausea
DTR
Blood pressure
Fetal heart tracing
Weight assessment
Respiratory assessment
Fundal height
Lower extremity assessment
Correct Answer : B,C,E,G,H
A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.
B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Naloxone is an opioid antagonist used to reverse opioid overdose, including respiratory depression caused by opioids such as hydromorphone.
B: Flumazenil is used to reverse benzodiazepine overdoses, not opioid overdoses.
C: Acetylcysteine is an antidote for acetaminophen overdose.
D: Protamine is used to reverse the effects of heparin, an anticoagulant
Correct Answer is D
Explanation
A. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
B. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
C. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
D. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
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