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A nurse is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

dark red vaginal bleeding, and abdominal pain

pain a 7 on a scale of 0 to 10

"My blood pressure has been high during the pregnancy."

Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

116/min, minimal variability noted

bilateral breath sounds clear

tearful

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

Rationale:

Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.

Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.

Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.

FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Keeping a newborn on NPO (nothing by mouth) status may be required in specific situations but not generally for routine care.

B. Laxatives are not routinely administered to newborns unless medically indicated for constipation.

C. Applying heat to the abdomen is not appropriate unless ordered by a healthcare provider, especially if the infant's temperature regulation is compromised.

D. Placing the head of the bed flat can help with positioning the newborn to prevent any breathing difficulties or aspiration.

A. "I'm feeling much better." B. less fatigue C. difficulty sleeping D. not sad anymore E. frequent headaches F. Client continues to deny any suicidal ideation. G. BP 169/91 mm Hg H. Heart rate 78/min I. Respiratory rate 18/min

Correct Answer is ["C","E","G"]

Explanation

Difficulty sleeping: This can be a side effect of fluoxetine, which can cause insomnia in some individuals.
Frequent headaches: Headaches are a common side effect of many antidepressants, including fluoxetine.
BP 169/91 mm Hg: Elevated blood pressure can be an adverse effect of fluoxetine, especially if the client has a history of hyperlipidemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining care for a clieture of a newborn. Which of the following sites should the nurse use?

Correct Answer is D

Explanation

Correct Answer is ["C","E","G"]

Explanation

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