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Patient Data

Exhibits

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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 snows 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.

client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station

contractions are occurring every 4 minutes and lasting 70 seconds

fasting blood glucose (FSBG) is 86 (4.8 mmol/L)

client dilates quickly to 10 cm and feels a strong urge to push

fetal heart rate is reassuring with a baseline of 145 and moderate variability

Apgar of 7 at 1 minute, then 9 at 5 minutes

After three cycles of open-glottis pushing, the baby's head is crowning

infant weighs 9 lbs. 9 oz

membranes rupture at 38 weeks gestation

Answer and Explanation

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

This blood glucose level is within the normal range, indicating that the client’s blood sugar is well-controlled at this point.

The client is 3 cm dilated, 40% effaced, with contractions every 4 minutes lasting 70 seconds and strong in quality. These are signs of active labor progressing appropriately.

The fetal heart rate is reassuring with a baseline of 145 beats per minute and moderate variability. This indicates good fetal well-being and adequate oxygenation.

The client quickly dilates to 10 cm and experiences a strong urge to push, suggesting efficient progress through labor.

The baby is born with an intact perineum, weighs 9 lbs. 9 oz (4.34 kg), and has excellent Apgar scores of 7 at 1 minute and 9 at 5 minutes. These scores indicate that the infant is in good condition and adapting well to extrauterine life.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Muscle pain can be a sign of rhabdomyolysis, a serious side effect of lovastatin that requires immediate evaluation and intervention.

B. Altered taste is a less serious side effect and does not require urgent follow-up.

C. Diarrhea and flatulence are common and less urgent side effects of lovastatin.

D. Abdominal cramps are uncomfortable but less critical compared to muscle pain associated with potential rhabdomyolysis.

A. Monitor oxygen saturation (SpO2) via continuous pulse oximetry. B. Observe neck for jugular vein distention. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is A

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

While conducting dietary teaching to the parent of an 11-month-old who was diagnosed with milk baby anemia, which food(s) should the nurse encourage the parent to offer the infant? Select all that apply.

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.