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 D

Explanation

A. "I can have a meal up to 2 hours before the procedure." Eating before an intravenous pyelogram (IVP) is not recommended, as fasting is typically required to prevent interference with imaging and reduce the risk of nausea from the contrast dye. Clients are usually instructed to refrain from eating for several hours before the procedure.
B. "I should limit my fluid intake for 2 days after the procedure." Increasing, rather than limiting, fluid intake is advised after the procedure to help flush the contrast dye from the kidneys and reduce the risk of nephrotoxicity. Adequate hydration is essential for kidney function following contrast administration.
C. "I do not need to sign a consent form before this procedure." An IVP involves the injection of contrast dye, which carries risks such as allergic reactions and kidney impairment. Because it is an invasive diagnostic procedure, informed consent is required before proceeding.
D. "I will feel a warming sensation after the injection of the dye." The contrast dye used in an IVP often causes a transient warm or flushed feeling, as well as a metallic taste in the mouth. This is a common and expected reaction, indicating that the client understands the procedure.

A. Hypotension B. Hearing loss C. Hyperthermia D. Constipation

Correct Answer is B

Explanation

A. Hypotension: Gentamicin is an aminoglycoside antibiotic that primarily affects the kidneys and auditory system rather than blood pressure. Hypotension is not a common adverse effect of gentamicin; however, dehydration related to nephrotoxicity could contribute to blood pressure fluctuations.
B. Hearing loss: Ototoxicity is a known adverse effect of gentamicin due to its accumulation in the inner ear, leading to damage of the cochlear and vestibular structures. Clients may report tinnitus, dizziness, or difficulty hearing, and prolonged exposure increases the risk of irreversible auditory impairment.
C. Hyperthermia: Fever is typically a sign of infection rather than an adverse effect of gentamicin. While aminoglycosides can cause fever in rare cases due to a drug-induced reaction, hyperthermia is not a common side effect and should prompt evaluation for worsening infection or another underlying cause.
D. Constipation: Gentamicin does not significantly affect gastrointestinal motility. While some antibiotics may cause gastrointestinal upset, nausea, or diarrhea, constipation is not a recognized adverse effect of gentamicin therapy.

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

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client. Exhibits For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations 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?

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the- counter products as unsafe for use with enoxaparin?

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.