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Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Assessment

Findings

Nurses' Notes

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact

No uterine contractions noted.

FHR baseline 138, minimal variability.

No further reports of burning with urination.

Laboratory Results

WBC 12,000/mm2 (5,000 to 10,000/mm3)

Platelet count 188,000/mm3 (150,000 to 400,000/mm3)

Vital Signs

Temperature 37.1° C (98.7° F)

Blood pressure 120/78 mm Hg

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

No uterine contractions noted.

No further reports of burning with urination.

WBC 12,000/mm2 (5,000 to 10,000/mm3)

Temperature 37.1° C (98.7° F)

Membranes intact

FHR baseline 138, minimal variability.

Platelet count 188,000/mm3 (150,000 to 400,000/mm3)

Blood pressure 120/78 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Client rates lower back pain as 0 on a scale from 0 to 10:

On Day 1, the client reported lower back pain, which could be associated with uterine contractions or other complications. By Day 2, the pain has resolved completely, with the client reporting a pain level of 0/10. This is a clear sign of improvement in her condition, especially since pain is often a key indicator of progress in antepartum care.

No reports of vaginal discharge:

On Day 1, the client reported pinkish vaginal discharge, which can be indicative of preterm labor or other complications. By Day 2, the absence of vaginal discharge suggests that the situation has improved, and the risk of preterm labor may be decreasing.

No uterine contractions noted:

On Day 1, the client had uterine contractions occurring every 8 minutes, which could be indicative of early labor or preterm labor. By Day 2, the absence of uterine contractions is a positive sign that the client is no longer experiencing early labor signs. This indicates that the situation is improving.

No further reports of burning with urination:

On Day 1, the client reported burning with urination, which was indicative of a urinary tract infection (UTI). On Day 2, the client no longer reports this symptom, suggesting that the urinary symptoms have resolved, and the infection may be improving, especially in light of ongoing treatment (e.g., antibiotics).

Laboratory Results Indicating Improvement:

WBC count 12,000/mm³ (Day 2) vs. 16,000/mm³ (Day 1):

The WBC count has decreased from 16,000/mm³ on Day 1 (which indicated infection or inflammation) to 12,000/mm³ on Day 2. Although the WBC count is still slightly elevated above the normal range (5,000-10,000/mm³), the decrease in WBC count suggests that the client's body is responding to treatment, and the infection or inflammation may be resolving.

Vital Signs Indicating Improvement:

Temperature 37.1° C (98.7°F) (Day 2) vs. 38.4° C (101.1°F) (Day 1):

The client’s fever has resolved, with a temperature decrease from 38.4°C (101.1°F) on Day 1 to 37.1°C (98.7°F) on Day 2. Fever is a common sign of infection, and the reduction in temperature suggests that the infection (likely a urinary tract infection) is being controlled and is improving.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. The incentive spirometer should be used more frequently (every 1-2 hours) to promote lung expansion and reduce the risk of pneumonia.
B. Bed rest should be minimized to promote circulation and reduce the risk of deep vein thrombosis (DVT).
C. Range-of-motion exercises improve circulation, prevent joint stiffness, and promote overall mobility.
D. Placing a pillow under the knees can interfere with circulation and promote flexion contractures.

A. Use the balloon port to obtain the sterile specimen. B. Disconnect the catheter from the collection tubing. C. Unclamp the collection port below the bag. D. Obtain the specimen from the retention port.

Correct Answer is D

Explanation

A. Using the balloon port can contaminate the specimen and is not the proper method to obtain a sterile sample.
B. Disconnecting the catheter from the collection tubing can increase the risk of infection.
C. Unclamping the collection port could cause urine to back up into the catheter and introduce bacteria.
D. The retention port should be used to obtain a sterile specimen from the catheter, as it is designed for this purpose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?

Correct Answer is D

Explanation

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