A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

Heart rate 98/min

Temperature 38.0 °C (100.4 °F)

Respiratory rate 14/min

Blood pressure 142/88 mm Hg

Answer and Explanation

The Correct Answer is B

A. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.

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Correct Answer is C

Explanation

A. "If I keep gaining weight, I will be miserable." Expressing anxiety about weight gain reflects a lack of emotional readiness and acceptance regarding the physical changes that accompany pregnancy.
B. "I cannot believe I got pregnant. We really weren't even trying to have a baby." Indicating surprise suggests a lack of preparation for the emotional and practical aspects of pregnancy. This reflects that the client may not have fully accepted the reality of the situation.
C. "I understand that hormonal changes can cause me to be happy one minute and sad the next." Recognizing and accepting the emotional fluctuations that can occur during pregnancy due to hormonal changes indicates a level of emotional preparation for the journey ahead.
D. "This baby will totally change my lifestyle, and I am not sure I am ready for all of this." Acknowledging the impact of having a baby on lifestyle is important, but expressing uncertainty suggests that the client may still be struggling with the implications of becoming a parent.

A. Positive Chvostek's sign B. Hypotension C. Confusion D. Positive Babinski reflex

Correct Answer is A

Explanation

A. Positive Chvostek's sign. Hypocalcemia increases neuromuscular excitability, leading to involuntary twitching of facial muscles when the facial nerve is tapped. This sign is a well-known indicator of calcium deficiency and reflects heightened nerve sensitivity.
B. Hypotension. While severe hypocalcemia can affect cardiovascular function, hypotension is not a primary or consistent finding. More commonly, calcium imbalances affect muscle contractions rather than directly causing low blood pressure.
C. Confusion. Hypocalcemia can cause neurological symptoms, but confusion is more common in severe or prolonged cases. Early manifestations are usually neuromuscular, such as tetany or muscle cramps, rather than cognitive impairment.
D. Positive Babinski reflex. This reflex is associated with upper motor neuron dysfunction and neurological disorders rather than electrolyte imbalances like hypocalcemia. Calcium deficiency primarily affects peripheral nerves and muscle excitability.

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A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

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