A nurse is caring for a 32-year-old female client who is at 32 weeks of gestation and has complete placenta previa. The client is in the obstetric unit.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.

Hematocrit

Fundal height

Vaginal bleeding

Platelet count

Fetal heart rate

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale: The client’s hematocrit level is 27%, which is below the normal range (greater than 39%). This could indicate anemia, which can be caused by blood loss. Given the client’s report of a “gush” of blood and the nurse’s observation of a moderate amount of bright red vaginal bleeding, this is a concerning finding that requires immediate follow-up. Anemia in pregnancy can lead to complications such as preterm birth, low birth weight, and maternal mortality.

Choice B rationale: The client’s fundal height is 33 cm, which is appropriate for a gestational age of 33 weeks. Fundal height is measured from the top of the pubic bone to the top of the uterus, and in centimeters, it should roughly equal the number of weeks of gestation. Therefore, this finding does not require immediate follow-up.

Choice C rationale: The client reports feeling a “gush” of blood and the nurse observes a moderate amount of bright red vaginal bleeding. This is a concerning finding given the client’s diagnosis of complete placenta previa, a condition where the placenta

completely covers the cervix. Vaginal bleeding in this context can indicate placental abruption, a serious complication where the placenta detaches from the uterus before childbirth. This requires immediate follow-up.

Choice D rationale: The client’s platelet count is 160,000/mm³, which is within the normal range (150,000 to 400,000/mm³). This indicates that the client’s blood clotting function is currently adequate. While platelet count can decrease with significant blood loss, the client’s current platelet count does not indicate a potential complication of pregnancy.

Choice E rationale: The client’s fetal heart rate is 174/min, which is above the normal range (110 to 160/min). This could indicate fetal tachycardia, which can be a response to maternal blood loss, maternal fever, or fetal hypoxia. This is a concerning finding that requires immediate follow-up.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

•   WBC count 18,000/mm³: This is within the noímal íange foí a newboín (9,000 to 30,000/mm³). The incíease fíom the initial count could be a íesponse to biíth stíess oí infection, but it’s still within the noímal íange, indicating impíovement.
•   Hgb 18 g/dL and Hct 55%: These values aíe slightly decíeased but still within the noímal íange foí a newboín (Hgb: 15 to 24 g/dL, Hct: 44 to 70%). These changes aíe likely uníelated to the newboín’s condition.
•   Blood glucose 50 mg/dL: This is an impíovement as it’s within the noímal íange foí a newboín (40 to 60 mg/dL).
•   Axillaíy tempeíatuíe 36.8°C: This is closeí to the noímal íange (36.5 to 37.5°C) compaíed to the initial tempeíatuíe, indicating impíovement.
•   Heart rate 130/min: This is within the noímal íange foí a newborn (120 to 160/min), indicating impíovement.

A. Yellow exudate will form at the surgical site in 24 hours B. The Plastibell will be removed 4 hours after the procedure C. Make sure the newborn’s diaper is snug D. Notify the provider if the end of your baby’s penis appears dark red

Correct Answer is A

Explanation

This is the correct answer. After a Plastibell circumcision, a yellow exudate, which is part of the normal healing process, will form at the surgical site within 24 hours.
Choice B rationale
The Plastibell device is not removed 4 hours after the procedure. It falls off naturally after seven to 10 days.
Choice C rationale
Making sure the newborn’s diaper is snug is not a specific instruction related to the Plastibell circumcision technique.
Choice D rationale
Notifying the provider if the end of the baby’s penis appears dark red is not a specific instruction related to the Plastibell circumcision technique.

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A nurse is caring for a 32-year-old female client who is at 32 weeks of gestation and has complete placenta previa. The client is in the obstetric unit. Exhibits Which of the following assessment findings requires immediate follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately following birth. Exhibits A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

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A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

A nurse is caring for a client who is postpartum and has a perineal laceration. What findings place the client at risk for delayed wound healing?

A nurse is planning care for a patient who is 12 hours postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

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A nurse is caring for a 32-year-old female client who is at 32 weeks of gestation and has complete placenta previa. The client is in the obstetric unit.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.