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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Have the client store smaller tanks under his bed: Storing oxygen tanks under the bed poses a serious fire hazard and increases the risk of accidental tipping or damage. Proper storage requires a stable, upright position in a well-ventilated area away from flammable materials.
B. Ensure that the client checks the gauge weekly: Oxygen tanks should be checked daily to ensure adequate supply and to prevent sudden depletion. Waiting a week between checks could result in unexpected oxygen interruption, which is unsafe for clients dependent on supplemental oxygen.
C. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, and placing tanks near flammable materials such as curtains, drapes, or open flames increases the risk of fire. Proper placement in a clear, ventilated area is a critical safety measure for home oxygen therapy.
D. Store the oxygen tank wrench in a locked cabinet: While securing equipment is generally safe, the oxygen tank wrench must be readily accessible in case of emergency or the need to quickly turn off the oxygen. Locking it away could delay urgent intervention.
Correct Answer is C
Explanation
A. Aspirin: Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the gastric mucosa and increase the risk of gastrointestinal bleeding. It is contraindicated in clients with a history of peptic ulcer disease.
B. Ketorolac: Ketorolac is a very potent Non-Steroidal Anti-Inflammatory Drug (NSAID) usually given IV or IM. It carries a high risk of GI ulceration and perforation and is contraindicated in clients with active PUD or a high risk of GI bleeding.
C. Acetaminophen: Acetaminophen provides analgesic and antipyretic effects without significant gastrointestinal irritation. It is safe for clients with peptic ulcer disease, making it the preferred choice for headache management in this context.
D. Ibuprofen: Ibuprofen, like other NSAIDs, can exacerbate peptic ulcer disease by inhibiting prostaglandin synthesis and increasing the risk of GI bleeding, so it should be avoided in clients with a history of ulcers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.