Try Naxlex NCLEX-RN (Free-Trial)

A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

Exhibits

Select the 5 findings that the nurse should recommend for follow-up.

Persistent headache

Nausea and vomiting

Right epigastric pain

Slight facial edema

Heart rate of 88/min

Blood pressure of 140/90 mmHg

Proteinuria 2+

Deep tendon reflexes (DTR) 3+ bilaterally

Answer and Explanation

Correct Answer : A,B,C,G,H

The correct answer is choice A. Persistent headache, B. Nausea and vomiting, C. Right epigastric pain, G. Proteinuria 2+, H. Deep tendon reflexes (DTR) 3+ bilaterally. Choice A rationale: Persistent headache is a significant symptom that can indicate increased intracranial pressure or other serious conditions, especially in a pregnant client. It requires follow-up to rule out complications such as preeclampsia. Choice B rationale: Nausea and vomiting, particularly when severe and persistent, can lead to dehydration and electrolyte imbalances. In the context of pregnancy, it can also be a sign of a more serious underlying condition that needs to be addressed. Choice C rationale: Right epigastric pain is concerning as it can be indicative of liver involvement, which is a serious complication in pregnancy. This symptom needs immediate follow-up to assess for conditions such as HELLP syndrome. Choice D rationale: Slight facial edema can be a normal finding in pregnancy, but it can also be a sign of fluid retention associated with preeclampsia. However, on its own, it is not as critical as the other symptoms listed. Choice E rationale: A heart rate of 88/min is within the normal range for adults and does not typically require follow-up unless accompanied by other concerning symptoms. Choice F rationale: Blood pressure of 140/90 mmHg is elevated and concerning in pregnancy, but it is not included in the correct answers because the other symptoms are more directly indicative of severe complications. Choice G rationale: Proteinuria 2+ is a significant finding that suggests kidney involvement and is a key diagnostic criterion for preeclampsia. This requires immediate follow-up. Choice H rationale: Deep tendon reflexes (DTR) 3+ bilaterally are hyperactive and can indicate neurological irritability, which is a concerning sign in the context of preeclampsia. This finding needs follow-up to prevent complications such as seizures. Choice I rationale: Fundal height measurement of 26 cm at 30 weeks of gestation is below the expected range and may indicate intrauterine growth restriction (IUGR) or other issues, but it is not as immediately critical as the other findings listed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.

A. I can use synthetic blankets on my bed." B. I can use isopropyl alcohol to clean the nasal cannula when necessary." C. I will increase the flow rate if I feel short of breath." D. "I will check my oxygen equipment at least once daily."

Correct Answer is D

Explanation

The client should check their oxygen equipment at least once daily to ensure proper functioning and safety. The other statements are incorrect and indicate a need for further teaching.

View Question and Answer

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

A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation. Exhibits Select the 5 findings that the nurse should recommend for follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immediately to the provider? Select all that apply.

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

Exhibits

Select the 5 findings that the nurse should recommend for follow-up.