Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Options:

Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

A. Sputum characteristics B. Respiratory complaint C. Blood pressure D. Heart rate Temperature E. Weight F. Travel history G. Oxygen saturation

Correct Answer is ["A","B","E","F"]

Explanation

A. Sputum characteristics. The presence of blood-tinged sputum raises concern for tuberculosis (TB) or another serious pulmonary condition, requiring further evaluation. Hemoptysis can indicate active infection or cavitary lung disease.
B. Respiratory complaint. The client reports a persistent, productive cough, night sweats, and fatigue, which are hallmark symptoms of TB. These symptoms, combined with recent travel to a TB-endemic region, increase the likelihood of infection and warrant further assessment.
C. Blood pressure. The client’s blood pressure is within the normal range and does not indicate an immediate concern requiring further evaluation.
D. Heart rate. A heart rate of 98/min is elevated but still within an acceptable range for mild illness or fever. While tachycardia can be associated with infection, it is not the most critical finding requiring urgent follow-up.
E. Temperature. A temperature of 38.1°C (100.5°F) indicates a low-grade fever, which is a common sign of TB or other infections. Given the client's symptoms and history, this finding warrants further investigation.
F. Travel history. The client recently traveled to South Africa, a region with a high prevalence of TB. Travel history is a crucial factor in determining TB risk and must be considered in the diagnostic process.
G. Oxygen saturation. The client’s oxygen saturation is 98% on room air, which is within normal limits and does not require further evaluation at this time.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The preschooler is at risk for developing dropdownevidenced by the preschooler'sdropdown

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

The nurse is preparing the client for discharge. Exhibits Which of the following statements indicate the client understands the discharge teaching? Select the 3 client statements that indicate an understanding of the teaching.

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

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.