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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.

A. Client experiences nightmares B. Heart rate 99/min C. Attends school regularly D. Smoking marijuana to clear their mind E. Startles easy during thunderstorm Witnessing their family's death F. BP 122/80 mm Hg G. Caregiver reporting client acting differently than usual

Correct Answer is ["A","D","E","G"]

Explanation

A. The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B. A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C. While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D. The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E. Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is

necessary to assess the client's mental health status and provide appropriate support and counseling.
F. A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G. The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being

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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation Exhibits Select the 5 findings that require follow up by the nurse

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client in a clinic. Exhibits Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.

Correct Answer is ["A","D","E","G"]

Explanation

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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation

Exhibits

Select the 5 findings that require follow up by the nurse