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 rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138, minimal variability. No further reports of burning with urination. |
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Laboratory Results |
WBC 12,000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3) |
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Vital Signs |
Temperature 37.1oC (98.7 oF) Blood pressure 120/78 mmHg |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge
Membranes intact
No uterine contractions noted
FHR baseline 138, minimal variability
No further reports of burning with urination
WBC 12,000/mm3 (5000 to 10000/mm3)
Platelet count 188000/mm3 (150000 to 400000/mm3)
Temperature 37.1oC (98.7 oF)
Blood pressure 120/78 mmHg
The Correct Answer is ["A","C","E","F","H","I"]
Nurses' Notes:
Client rates lower back pain a 0 on a scale from 0 to 10: Indicates pain resolution, suggesting improvement.
No reports of vaginal discharge: Suggests stabilization and no signs of labor progression.
No uterine contractions noted: Indicates that preterm labor is resolving.
No further reports of burning with urination: Suggests that the urinary tract infection (UTI) is improving.
Vital Signs:
Temperature 37.1°C (98.7°F): Fever has resolved, indicating response to antibiotics.
Blood pressure 120/78 mmHg: Remains stable within normal limits.
Laboratory Results:
WBC 12,000/mm³ (previously 16,000/mm³): Decreasing WBC count suggests resolution of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A deep tendon reflex of 2+ indicates that the magnesium sulfate is working appropriately to prevent seizures while avoiding toxicity.
B. Proteinuria is a sign of preeclampsia; however, 1+ proteinuria does not indicate the therapeutic effect of magnesium sulfate.
C. A pulse rate of 100/min does not indicate the effectiveness of magnesium sulfate therapy.
D. Urine output of 20 mL/hr is concerning, as it indicates decreased kidney function and possible magnesium toxicity. Normal urine output should be at least 30 mL/hr.
Correct Answer is D
Explanation
A. Prednisone should be taken with food to prevent gastrointestinal irritation.
B. Weight gain, not weight loss, is a common side effect due to fluid retention and increased appetite.
C. Prednisone should be taken in the morning, as it can cause insomnia if taken at bedtime.
D. Prednisone is a corticosteroid that increases the risk of osteoporosis by reducing calcium absorption, so clients should increase dietary calcium and vitamin D intake.
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