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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. "I've been wearing the same few things every day because most of my clothes don't fit anymore." This statement reflects a common experience during pregnancy as the body changes. While it may indicate some frustration, it does not necessarily suggest difficulty accepting body image changes.
B. "Dressing up for work is a little harder now that I can't wear high heels." This statement acknowledges an adjustment in clothing choices due to pregnancy but does not indicate distress about body image. Many individuals modify their footwear for comfort and safety as pregnancy progresses.
C. "I've had to start wearing nursing bras already because my breasts are growing so much." This statement reflects awareness of bodily changes rather than difficulty accepting them. Breast enlargement is a normal part of pregnancy, and choosing appropriate clothing to accommodate these changes suggests adaptation rather than distress.
D. "When I wear high-top yoga pants, they hold my belly in so you can't even tell I'm pregnant." This statement suggests an attempt to conceal the pregnancy, which may indicate discomfort with body image changes. Actively trying to hide the pregnancy rather than embracing the natural progression of body changes can be a sign of difficulty accepting the physical transformation.

A. "I can stop giving my child this medication if he is taking a steroid." B. "I will give this medication to my child once daily in the evening." C. "It takes 2 months of scheduled use before this medication is effective." D. "I will give this medication to my child every 2 hours if he is wheezing."

Correct Answer is B

Explanation

A. "I can stop giving my child this medication if he is taking a steroid." Montelukast is a leukotriene receptor antagonist used for long-term asthma management and should not be discontinued without consulting a provider. It can be used alongside inhaled corticosteroids for better asthma control.
B. "I will give this medication to my child once daily in the evening." Montelukast is typically administered once daily in the evening because leukotrienes contribute to airway inflammation and bronchoconstriction, which can be more pronounced at night. Evening administration maximizes its effectiveness in preventing asthma symptoms.
C. "It takes 2 months of scheduled use before this medication is effective." Montelukast begins to show effects within a few days to a few weeks of consistent use, not two months. However, it is not a rescue medication and should be taken regularly for long-term asthma control.
D. "I will give this medication to my child every 2 hours if he is wheezing." Montelukast is not a rescue medication and does not provide immediate relief for acute bronchospasms. A short-acting beta-agonist, such as albuterol, should be used for rapid symptom relief during wheezing episodes.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is assisting with the care of a client in an outpatient provider's office Exhibits Complete the following sentence by using the list of options. The nurse should identify that the client is at risk of developing dropdownand may requiredropdown

A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for this client?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

Exhibits

The client is at risk of developing
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and
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