A nurse is caring for a client who has been admitted to an antepartum unit.

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

History and Physical

Day 1, 0900:

30-year-old client who is at 33 weeks of gestation, gravida 4 para 3. Maternal blood type is Rh positive. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks of gestation. No known allergies.

Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 min, palpate strong, duration 30 seconds.

FHR baseline is 145/min, minimal variability.

Cervical examination indicates 2 cm, 50% effaced, 0 station.

Membranes are intact.

CBC and urinalysis collected and sent to laboratory.

Client reports lower back pain and pinkish vaginal discharge

Uterine contractions every 8 min, palpate strong, duration 30 seconds.

FHR baseline is 145/min, minimal variability.

Cervical examination indicates 2 cm, 50% effaced, 0 station.

Membranes are intact.

Answer and Explanation

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

Rationale for correct choices

• Lower back pain and pinkish vaginal discharge: Pinkish vaginal discharge, often called “bloody show,” is a sign of cervical changes and indicates progression of labor. In combination with lower back pain, contractions and cervical effacement, it suggests that preterm labor may be underway and requires close monitoring.

• Uterine contractions every 8 min, palpate strong, duration 30 seconds: Regular, strong contractions in the third trimester can signal preterm labor. Given the client’s history of preterm birth, this finding warrants close monitoring and possible interventions to halt labor progression or enhance fetal lung maturity.

• FHR baseline 145/min, minimal variability: Minimal variability in the fetal heart rate can indicate fetal hypoxia or stress. Continuous monitoring and assessment of maternal-fetal status are necessary to identify potential complications and guide interventions.

• Cervical examination 2 cm, 50% effaced: Cervical changes at 33 weeks indicate early cervical ripening, consistent with preterm labor. This finding requires follow-up to evaluate progression and implement appropriate interventions to prevent preterm birth.

Rationale for incorrect choices

• Membranes intact: Intact membranes indicate that preterm premature rupture of membranes has not occurred. This is reassuring and does not require immediate intervention, although ongoing assessment is needed.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Area of trauma: Trauma sites may have bruising, inflammation, or localized discoloration, which can mask or mimic cyanosis. Assessing these areas is unreliable for detecting systemic oxygenation deficits.

B. Shoulders: The shoulders are typically covered with more pigmented skin and subcutaneous tissue, making color changes less apparent. Cyanosis may be difficult to detect in these areas in clients with dark skin.

C. Sacrum: While the sacrum is prone to pressure injuries, it is not an optimal site for assessing cyanosis. Skin pigmentation and local pressure effects can obscure subtle changes in oxygenation.

D. Palms of the hands: The palms, along with the soles of the feet and nail beds, have less melanin and thinner epidermis, making them reliable sites for detecting cyanosis in clients with dark skin. Bluish discoloration in these areas can indicate hypoxemia.

A. Beneficence B. Fidelity C. Veracity D. Autonomy

Correct Answer is A

Explanation

A. Beneficence: Beneficence involves actions that promote the well-being of others and provide comfort, support, or care. By sitting with the client to offer emotional support following the loss of a partner, the nurse is actively promoting the client’s welfare and demonstrating compassion, which aligns with the ethical principle of beneficence.

B. Fidelity: Fidelity refers to maintaining trust and keeping promises or commitments to clients. While important in nursing, simply providing comfort through presence does not directly involve promise-keeping, making this principle less applicable in this scenario.

C. Veracity: Veracity is the obligation to tell the truth and provide accurate information. Sitting with the client for emotional support does not involve disclosure or truth-telling, so it is not the primary ethical principle demonstrated here.

D. Autonomy: Autonomy pertains to respecting a client’s right to make their own informed decisions about care. Providing comfort through presence supports well-being but does not involve facilitating or respecting decision-making in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

Correct Answer is D

Explanation

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

Correct Answer is A

Explanation

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps, placing them in the order of performance. Use all the steps.)

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