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A nurse is assisting in the care of a client on a labor and delivery unit.

Exhibits

Which of the following findings require further evaluation by the nurse?

Select all that apply.

Report of weight change

Client heart rate

Deep tendon reflexes

Fetal heart rate

Pain rating

Oxygen saturation level

Report of vaginal discharge

Answer and Explanation

Correct Answer : B,D,E,G

A. Report of weight change. A slight weight loss near term is a common finding as the body prepares for labor. This is not an immediate concern.
B. Client heart rate. The heart rate increased from 90/min at 0830 to 110/min at 0845. A rising maternal heart rate could indicate dehydration, pain, or early signs of infection.
C. Deep tendon reflexes. Reflexes are documented as 2+, which is within the expected range and does not indicate hyperreflexia or hyporeflexia.
D. Fetal heart rate. The FHR at 1530 is 120/min with late decelerations, which is concerning. Late decelerations suggest uteroplacental insufficiency, requiring further assessment and possible interventions such as maternal repositioning, oxygen administration, or fluid bolus.
E. Pain rating. The client reports severe back pain rated as 10/10, which may indicate fetal malposition (such as occiput posterior positioning) or rapid labor progression, both requiring evaluation and possible intervention.
F. Oxygen saturation level. The oxygen saturation has remained stable between 96% and 97%, which is within the expected range and does not require immediate intervention.
G. Report of vaginal discharge. An increased amount of blood-tinged discharge at 1530 may indicate cervical dilation or potential complications such as placental abruption, especially in the presence of late decelerations.

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Correct Answer is B

Explanation

A. "Our child has increased his daily caloric intake." Methylphenidate is a stimulant that commonly suppresses appetite, leading to decreased caloric intake and potential weight loss. An increase in appetite would not indicate medication effectiveness but might suggest the dose is too low or the medication is wearing off.
B. "Our child is able to complete his homework on time." Methylphenidate is used to improve attention, impulse control, and focus in children with ADHD. The ability to complete tasks, such as finishing homework on time, demonstrates improved concentration and executive functioning, which indicates the medication is working effectively.
C. "Our child has a better grasp of reality." ADHD is not primarily associated with a loss of reality testing, as seen in psychotic disorders. While methylphenidate improves focus and impulse control, it does not target symptoms such as delusions or hallucinations.
D. "Our child has lost some weight since his last appointment." Weight loss is a common side effect of methylphenidate due to appetite suppression. While this can be monitored, it does not indicate medication effectiveness in treating ADHD symptoms.

A. Cottage cheese B. Bran muffin C. Tomato juice D. Puffed rice cereal

Correct Answer is B

Explanation

A. Cottage cheese: Cottage cheese is low in fiber and does not promote bowel regularity. A diet high in fiber is recommended to help soften stool and stimulate peristalsis, which is necessary for relieving constipation.
B. Bran muffin: Bran is an excellent source of dietary fiber, which adds bulk to stool and facilitates easier bowel movements. High-fiber foods, such as whole grains, fruits, and vegetables, are essential in managing constipation effectively.
C. Tomato juice: While tomato juice contains some nutrients, it is not a significant source of fiber. Increasing fiber intake is more beneficial for constipation than consuming low-fiber liquids. However, adequate hydration is still important in preventing hard stools.
D. Puffed rice cereal: Puffed rice cereal is typically refined and low in fiber, making it a poor choice for relieving constipation. Whole grains, such as bran, oatmeal, or whole wheat products, are more effective in promoting bowel regularity.

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A nurse is assisting in the care of a client on a labor and delivery unit. Exhibits Which of the following findings require further evaluation by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting in the care of a client on a labor and delivery unit.

Exhibits

Which of the following findings require further evaluation by the nurse?

Select all that apply.