Exhibits

The client is at risk of developing
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and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The preschooler is at risk for developing atelectasis evidenced by the preschooler's refusal to use the spirometer.

Atelectasis, or lung collapse, is a common postoperative complication due to shallow breathing and inadequate lung expansion. In this case the child refuses to use the incentive spirometer, which is crucial for preventing atelectasis by encouraging deep breathing. Shallow respirations are noted in both assessments, indicating reduced lung expansion.

A. Anterior fontanel closed B. Moves objects to mouth C. Rolls from back to abdomen D. Posterior fontanel closed

Correct Answer is A

Explanation

A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The preschooler is at risk for developing dropdownevidenced by the preschooler'sdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

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?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse is caring for a client in an outpatient clinic. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdownevidenced by the client'sdropdown

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is at 26 weeks of gestation. Which of the following statements indicates the client is having difficulty accepting the body image changes associated with pregnancy?

A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?

Exhibits

The client is at risk of developing
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and
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