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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Directing anyone who becomes angry to leave the room may escalate tensions and hinder resolution.
B: Establishing demands from each party can create a confrontational atmosphere where parties are more focused on winning than resolving the conflict.
C: In resolving staff conflicts, facilitating discussion until all parties agree is a constructive strategy that promotes understanding and collaboration. This approach encourages open communication, allows for the expression of different viewpoints, and works towards a consensus that respects everyone's needs and concerns.
D: Determining fault can increase defensiveness and hinder collaboration in resolving the conflict. It is counterproductive as it places blame, which can lead to defensiveness and hinder the resolution process.
Correct Answer is A
Explanation
A. Fever is a common manifestation of bacterial pneumonia, as it indicates the body's immune response to infection. Other typical symptoms include cough, shortness of breath, chest pain, and sputum production.
B. Drooling is not typically associated with bacterial pneumonia but may occur in conditions such as epiglottitis or aspiration pneumonia.
C. Tinnitus is not a characteristic manifestation of bacterial pneumonia but may occur with other conditions affecting the ear.
D. Steatorrhea refers to fatty stools and is not associated with pneumonia.
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