The nurse continues to care for the client.
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
|
Assessment |
Findings |
|
Nurses' Notes |
Client reports lower back pain as 0 on a scale from 0 to 10 No reports of vaginal discharge Membranes are intact. No uterine contractions noted. FHR baseline 138/min, minimal variability. No further reports of burning with urination. |
|
Vital Signs |
Temperature 37.1° C (98.7° F) Blood pressure 120/76 mm Hg |
|
Laboratory Results
|
WBC count 12,000/mm3 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm) |
Client reports lower back pain as 0 on a scale from 0 to 10
No reports of vaginal discharge
No uterine contractions noted.
FHR baseline 138/min, minimal variability.
No further reports of burning with urination.
Temperature 37.1° C (98.7° F)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
The Correct Answer is ["A","B","C","E","F","G"]
Rationale for correct choices
• Client reports lower back pain as 0 on a scale from 0 to 10: Resolution of back pain suggests that uterine contractions and associated discomfort have decreased, indicating reduced preterm labor activity and improved comfort. Pain control and labor suppression interventions appear effective.
• No further reports of burning with urination: The absence of dysuria indicates that a possible urinary tract infection is improving, either spontaneously or following interventions such as increased hydration or antibiotic therapy. Symptom resolution reflects clinical improvement.
• No uterine contractions noted: The absence of contractions indicates that preterm labor activity has decreased. This reflects effective management and a positive trend in preventing progression to preterm birth.
• Temperature 37.1° C (98.7° F): A normalized temperature reflects a reduction in maternal infection or inflammatory response. This indicates that the client’s fever is resolving, decreasing risk for maternal and fetal complications.
• No reports of vaginal discharge: The absence of abnormal vaginal discharge suggests that cervical or infection-related changes are resolving, reflecting decreased risk of preterm labor progression
• WBC count 12,000/mm³: The white blood cell count has decreased from the initial 16,000/mm³, showing a positive response to antibiotic therapy. A decrease from the previous elevated WBC count indicates that infection or inflammation is resolving, demonstrating laboratory improvement and decreased maternal risk.
Rationale for incorrect choices
• FHR baseline 138/min, minimal variability: A baseline fetal heart rate within normal limits is reassuring, but minimal variability persists, indicating continued need for monitoring. This alone does not indicate full clinical improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fax the client's name and identifiable information to the rehabilitation facility: Faxing client information without encryption or secure transmission can expose sensitive data to unauthorized individuals. This does not fully protect confidentiality under HIPAA regulations.
B. Provide a verbal report of the client's condition to the paramedic performing the transfer: Sharing necessary health information directly with authorized personnel involved in the client’s care is appropriate and protects confidentiality. Verbal handoff ensures the receiving team has critical information while limiting exposure to unauthorized parties.
C. Email the client's health information to the facility in an unencrypted file: Sending unencrypted health information via email is unsafe and violates HIPAA guidelines. Unauthorized access could compromise the client’s privacy and confidentiality.
D. Discuss the client's response to the transfer with another staff nurse: Discussing the client’s health information with staff members not directly involved in the transfer or care constitutes a breach of confidentiality. Only pertinent staff members should receive the information.
Correct Answer is A
Explanation
A. Clean blood-contaminated surfaces with bleach: HIV can be transmitted through contact with infected blood. Using a bleach solution to disinfect blood-contaminated surfaces effectively kills the virus, making this an essential infection-prevention measure.
B. Buy disposable dishes for daily use: HIV is not transmitted through casual contact or shared dishes, utensils, or food. Encouraging disposable dishes is unnecessary and does not contribute to infection prevention.
C. Wash soiled clothes in cold water: HIV is not transmitted through clothing or laundry. Additionally, washing in cold water is less effective at removing pathogens; hot water with detergent is preferred for general hygiene, but special precautions for HIV are not required.
D. Use condoms with a petroleum-based lubricant: Petroleum-based lubricants can degrade latex condoms, increasing the risk of breakage. Clients should use water-based or silicone-based lubricants with condoms to reduce the risk of HIV transmission.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.