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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)

Answer and Explanation

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

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.

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Free Nursing Study Resources

Correct Answer is A,B,C,D

Explanation

A. Lubricate the catheter with sterile saline: Lubrication reduces friction and trauma to the tracheal mucosa during insertion, facilitating smoother catheter advancement and minimizing irritation.

B. Insert the catheter until resistance is felt: The catheter is advanced gently until the first point of resistance, which indicates proximity to the carina or a main bronchus. This prevents excessive insertion that could injure airway structures.

C. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in): Withdrawing slightly before applying suction helps avoid direct trauma to the carina while still targeting secretions in the larger airways for effective clearance.

D. Rotate the catheter while suctioning: Rotating the catheter while applying suction maximizes removal of secretions from the trachea and bronchi while distributing suction forces evenly, reducing the risk of mucosal injury.

A. Client states, "I'm nauseated all the time B. I've been a little constipated, but it's not too bad C. Abdomen without tenderness on palpation D. Bowel sounds hypoactive. E. Oral mucous membranes sticky F. Also reports they are urinating less and that urine is dark yellow and odorous G. No edema H. Blood pressure 102/66 mm Hg I. Urine noted to be dark yellow and concentrated

Correct Answer is ["A","D","E","F","H","I"]

Explanation

Rationale for correct choices

• Gastrointestinal: Persistent nausea and frequent vomiting in early pregnancy can lead to dehydration, electrolyte imbalance, and malnutrition. Hypoactive bowel sounds and dry mucous membranes further suggest fluid deficit and possible electrolyte disturbances. Reporting these findings allows the provider to assess severity and initiate interventions.

• Genitourinary: Oliguria and dark, concentrated urine indicate potential dehydration, which can exacerbate nausea and vomiting and compromise kidney function. Early reporting is critical to prevent complications such as acute kidney injury.

• Cardiovascular: The relative hypotension as compared to the baseline blood pressuremay reflect compensatory tachycardia due to dehydration or volume depletion. These vital sign changes warrant reporting because they help the provider assess hemodynamic stability and guide fluid management.

Rationale for incorrect findings:

• Constipation and abdominal palpation without tenderness: Mild constipation without abdominal tenderness is common in early pregnancy due to hormonal changes and is not immediately concerning. It can be managed with dietary fiber, hydration, and gentle activity.

• No edema: The absence of edema indicates no overt fluid retention or preeclampsia at this stage. While monitoring continues, this finding does not require urgent reporting.

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Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

Correct Answer is ["A","D","E","F","H","I"]

Explanation

Answer by using the lists of options. The client likely experienced dropdown as evidenced by dropdown.

The nurse continues to care for the client. Which of the following actions should the nurse take? Select all that apply.

A nurse on a postpartum unit is caring for a client. Complete the following sentence by using the lists of options. The client is most likely experiencing _____ as evidenced by the client's _____ .

The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

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