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A nurse is reviewing the medical record of a client who is postpartum and has preeclampsi

Hct 39.6

Serum albumin 4.5 g/dL

WBC 9.000/mm

Platelets 50,000/mm

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Hct 39.6 is incorrect. This hemoglobin level is within a typical range and may not require immediate intervention.

Choice B Reason:

Serum albumin 4.5 g/dL is incorrect. A serum albumin level of 4.5 g/dL is within the normal range and does not suggest an urgent issue.

Choice C Reason:

WBC 9,000/mm³ is incorrect. A white blood cell count of 9,000/mm³ is within the normal range and is not typically a cause for immediate concern in the absence of other symptoms or indications.

Choice D Reason:

Platelets 50,000/mm³ is correct. A platelet count of 50,000/mm³ is significantly below the normal range and may indicate thrombocytopenia, a condition associated with preeclampsi

A. Thrombocytopenia in preeclampsia can lead to bleeding complications and requires close monitoring and management.

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Correct Answer is B

Explanation

The correct answer is B. Explain to the client this is an expected occurrence.

A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.

B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.

C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.

D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.

A. Increase the oxytocin infusion to 13 mu/min B. Place client in a side-lying position C. initiate bolus of primary IV fluids D. Apply oxygen at 10 L/min via venturi mask E. Perform sterile vaginal examination (SVE) F. Assign a bishop score

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Increase the oxytocin infusion to 13 mu/min:

Anticipated: This action is anticipated. The nurse may consider adjusting the oxytocin infusion rate based on the progress of labor and the response to the current infusion rate.

Place client in a side-lying position:

Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

Initiate bolus of primary IV fluids:

Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.

Apply oxygen at 10 L/min via a venturi mask:

Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.

Perform sterile vaginal examination (SVE):

Nonessential: Based on the information provided, there is no indication for a sterile vaginal examination at this time. The cervical assessment was performed earlier at 0600, and frequent unnecessary SVEs can increase the risk of infection.

Assign a Bishop score:

Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed earlier at 0600, and the current focus is on monitoring the progress of labor with oxytocin.

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A nurse is reviewing the medical record of a client who is postpartum and has preeclampsi

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is 42 weeks of gestation Nurses Notes Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

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