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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.

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Correct Answer is C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

A. A B. B C. C D. D

Correct Answer is {"xRanges":[125.765625,155.765625],"yRanges":[492.609375,522.609375]}

Explanation

The dorsalis pedis artery pulse can be palpated lateral to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.

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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 preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[125.765625,155.765625],"yRanges":[492.609375,522.609375]}

Explanation

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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.