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A nurse is caring for a client at 39 weeks gestation

Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Vital Signs

1130

Oral temperature 38.3 C (101 F )

Heart rate 98min

Respiratory rate 18/min

Blood pressure 112/59 mm Hg

Oxygen saturation 98% on room air

Nurses Notes

1130

Client states, ‘I think my water broke. The pad under me is soaked’. Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 mins moderate to palpation. Fetal heart rate is 140/min.

Diagnostic Results

1200

HGB 10 g/dl (greater than 11 g/dl)

HCT 34% (greater that 33%)

WBC 22,000 ( 5,000 – 11,000)

Oral temperature 38.3 C (101 F )

HGB 10 g/dl (greater than 11 g/dl)

Heart rate 98min

Blood pressure 110/60 mm Hg

Uterine contractions every 3 mins moderate to palpation

Answer and Explanation

The Correct Answer is ["A","B"]

Oral temperature 38.3°C (101°F)
Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
HGB 10 g/dL (normal > 11 g/dL)
Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

Heart rate 98/min: Slightly elevated but within normal range for labor.
Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

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Correct Answer is B

Explanation

A. Constipation is not directly associated with hyperemesis gravidarum.
B. Ketonuria occurs due to prolonged vomiting and starvation, indicating fat breakdown for energy.
C. Hypertension is unrelated to hyperemesis gravidarum.
D. Polyhydramnios refers to excessive amniotic fluid and is not a feature of hyperemesis gravidarum.

A. Monitor cervical dilation. B. Ask the client about the color of the water. C. Obtain the client's vaginal pH. D. Determine the fetal heart rate.

Correct Answer is D

Explanation

A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following clinical findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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