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.
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Assessment |
Findings |
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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. |
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Vital Signs |
Temperature 37.1° C (98.7° F) Blood pressure 120/76 mm Hg |
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Laboratory Results
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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 A
Explanation
A. State Nurse Practice Act: The State Nurse Practice Act defines the legal scope of practice for nurses within that state, including permissible tasks, delegation guidelines, and licensure requirements. Consulting it ensures that the nurse acts within legal and professional boundaries.
B. Verbal direction from the nurse manager: While guidance from a manager can clarify expectations, it does not supersede legal regulations or define the nurse’s authorized scope of practice. Following only verbal instructions without legal backing may place the nurse at risk of practicing outside their scope.
C. Institutional policies and procedures: Policies provide guidance on how tasks should be performed safely within a facility, but they do not define the nurse’s legal scope of practice. These should be used in conjunction with state regulations, not as the primary authority.
D. Written prescription from the provider: A provider’s order indicates what care is needed for the client but does not grant a nurse legal authority to perform tasks outside their scope of practice. The nurse must ensure the action is permitted under state law before implementation.
Correct Answer is ["2"]
Explanation
Rationale:
- Convert the ordered dose to milligrams
Conversion factor: 1 mg = 1000 mcg
Ordered Dose: 50 mcg = 0.05 mg
- Identify the available tablet strength
Available Tablet Strength: 0.025 mg/tablet
- Calculate the number of tablets per dose
Number of Tablets = Dose ÷ Tablet Strength
= 0.05 ÷ 0.025
= 2 tablets
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