Scenario:

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client previously delivered vaginally three years ago under epidural anesthesia. Her current pregnancy has progressed normally with a weight gain of 28 lbs (12.7 kg) and no reported blood pressure issues. Group B Streptococcus screening is negative, and all pregnancy-related laboratory results, including rubella immunity, are within normal limits. The client has a blood type of O, Rh-positive.

Exhibits

The nurse teaches the client about the fetus's reaction to labor by:

Select the most appropriate options missing from the statements below. Describing heart rate patterns by
dropdown
Evaluating the relationship when a contraction occurs by
dropdown

Answer and Explanation

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

Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.

Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.

Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.

Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.

Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.

Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.

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Free Nursing Study Resources

Correct Answer is []

Explanation

TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.

Rationale for actions

Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.

Rationale for incorrect conditions

Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.

A. Paresthesia. B. Tremors. C. Tinnitus. D. Fever. E. Tachycardia.

Correct Answer is ["D","E"]

Explanation

Choice A rationale

Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.

Choice B rationale

Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.

Choice C rationale

Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.

Choice D rationale

Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.

Choice E rationale

Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Correct Answer is ["D","E"]

Explanation

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?