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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. Oxytocin. This medication is typically administered intravenously or intramuscularly to promote uterine contractions and control postpartum hemorrhage. It is not given via the sublingual or rectal route.
B. Misoprostol. This prostaglandin analog is effective in managing postpartum hemorrhage by stimulating uterine contractions. It can be administered via several routes, including oral, sublingual, and rectal, making it a versatile option in hemorrhage control. The rectal route is often preferred in emergencies due to rapid absorption and minimal gastrointestinal side effects.
C. Carboprost. This medication is a prostaglandin used to treat postpartum hemorrhage but is administered intramuscularly rather than sublingually or rectally. It is typically reserved for cases that do not respond to first-line treatments due to its potential for significant gastrointestinal and cardiovascular side effects.
D. Methylergonovine. This ergot alkaloid is effective in reducing postpartum hemorrhage by inducing strong uterine contractions. However, it is administered intramuscularly or orally and is contraindicated in clients with hypertension due to its vasoconstrictive properties.

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

Explanation

Rationale for Correct Options:

Compartment syndrome is a serious complication that can occur after a fracture, particularly of a long bone like the femur. It results from increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage.

Edema of the toes suggests swelling, which may indicate increasing pressure within the affected limb. The adolescent is already reporting significant pain (7/10) and has required repeated doses of IV morphine, which may not be sufficient to relieve compartment syndrome pain (a key warning sign). If left untreated, compartment syndrome can cause nerve and muscle damage, ischemia, and even permanent disability.

Rationale for Incorrect Options:

Deep Vein Thrombosis (DVT): DVT is a risk with immobilization, but it usually presents with unilateral swelling, warmth, and pain in the affected limb, not just toe edema.

Fat Embolism Syndrome: This occurs due to fat globules entering circulation after a long bone fracture. Symptoms include respiratory distress, mental status changes, and petechiae, which are not present here.

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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

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Correct Answer is B

Explanation

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

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.