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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","C","D"]

Explanation

B. Hand-to-mouth movements are an early hunger cue as the newborn tries to self-soothe or indicate readiness to feed.

C. Rooting reflex is a classic early sign where the newborn turns their head toward the stimulus (like a nipple) indicating hunger.

D. Sucking motions suggest the newborn is preparing or ready to feed.

A. Consistent crying is a late hunger cue and can indicate distress if earlier cues are missed.

E. The Babinski reflex is a neurological reflex unrelated to hunger cues.

Correct Answer is A

Explanation

A. The umbilical cord typically dries and falls off within 1 to 2 weeks after birth, which is a normal expectation.
B. Newborns do not need daily tub baths; a sponge bath 2–3 times a week is usually sufficient until the cord falls off.
C. Babies should always be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS), not on their sides.
D. The correct technique for using a bulb syringe is to compress it before inserting it into the baby’s mouth or nose, then release to suction out secretions.

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