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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)

A.

Oral temperature 38.3 C (101 F )

B.

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

C.

Heart rate 98min

D.

Blood pressure 110/60 mm Hg

E.

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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Related Questions

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

Explanation

A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.

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

Explanation

Statement

Include

Not Include

"Your baby needs to be repositioned every 2 to 3 hours while under the lights."

✅

"Your baby's eyes will be covered with an eye shield during therapy."

✅

"Avoid applying lotion to your baby's skin."

✅

"Keep a hat on your baby during treatment."

✅

"We will give your baby glucose water between breast feedings.

✅

"Bilirubin is primarily excreted through the stool."

✅

The treatment lights can cause a transient skin rash on your baby."

✅

The treatment lights emit a significant amount of ultraviolet radiation.

✅

  • Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
  • Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
  • Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
  • Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
  • Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
  • Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
  • Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
  • Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.

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