Exhibits
The postpartum nurse reviews the nurses' notes to determine if the outcomes were successful.
Click to highlight the notes that demonstrate a positive outcome.
The client is admitted to the hospital after her membranes rupture at 38 weeks gestation. A vaginal examination is done. The nurse determines that the client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor shows that contractions are occurring every 4 minutes and lasting 70 seconds, and the nurse palpates the quality as strong. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L). The client is transferred to the labor-delivery-recovery (LDR) suite. The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate is reassuring with a baseline of 145 and moderate variability The nurse briefly reviews pushing techniques with her and her husband and notifies the obstetrician of the client's progress. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum. The infant weighs 9 lbs. 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes.
Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L)
The client dilates quickly to 10 cm and feels a strong urge to push
The fetal heart rate is reassuring with a baseline of 145 and moderate variability
After three cycles of open-glottis pushing, the baby's head is crowning
The head is born easily over an intact perineum
The infant weighs 9 lbs. 9 oz (4.34 kgs)
Apgar of 7 at 1 minute, then 9 at 5 minutes
The Correct Answer is ["A","B","C","D","E","G"]
Rationale for Correct Findings:
- The client dilates quickly to 10 cm and feels a strong urge to push: Rapid dilation and the strong urge to push indicate that the client is progressing effectively through labor, with no signs of obstruction or delays.
- The fetal heart rate is reassuring with a baseline of 145 and moderate variability: A reassuring fetal heart rate with moderate variability is a good sign that the baby is not experiencing any distress during labor, indicating a healthy fetal condition.
- The head is born easily over an intact perineum: The ease of the baby's head being born over an intact perineum suggests that the delivery is progressing smoothly, with minimal risk of perineal trauma.
- Apgar of 7 at 1 minute, then 9 at 5 minutes: The Apgar scores of 7 at 1 minute and 9 at 5 minutes show a positive outcome in neonatal assessment, with a good recovery.
- The fasting blood glucose (FSBG) is 86 (4.8 mmol/L): A fasting blood glucose of 86 mg/dL is within the normal range (74 to 106 mg/dL), indicating that the client’s blood glucose levels are well-controlled, which is a positive sign for managing her gestational diabetes.
Rationale for Negative Finding:
- The infant weighs 9 lbs. 9 oz (4.34 kgs): Macrosomia (a term used for babies born weighing more than 4 kg) can be associated with gestational diabetes, which increases the likelihood of delivering a larger baby. Macrosomia may lead to potential complications such as shoulder dystocia or increased risk for cesarean delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.
B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.
C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.
D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.
Correct Answer is B
Explanation
A. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: There are no cures for Parkinson's disease, and suggesting that alternative treatments could cure it could create unrealistic expectations.
B. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: This response provides accurate information while being honest about the limitations of current treatments for Parkinson's disease.
C. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or conventional medications currently cure Parkinson’s disease. The nurse should avoid suggesting potential cures that are not based on scientific evidence.
D. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While this may be supportive for the wife, it does not directly address her question about treatment options. The focus should be on providing accurate information regarding the disease and treatment options.
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