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 37.1°C (98.7°F) 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 37.1<strong>°</strong>C (98.7<strong>°</strong>F)
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 D
Explanation
A. The shoulders are not the best place to assess cyanosis, as they may not show noticeable color changes.
B. Areas of trauma may show bruising or discoloration unrelated to cyanosis.
C. The sacrum is not the most visible site for assessing cyanosis in dark-skinned individuals.
D. The palms of the hands, soles of the feet, mucous membranes, and conjunctiva are the best areas to assess cyanosis in dark-skinned clients, as changes in oxygenation are more apparent in these regions.
Correct Answer is C
Explanation
A. A residual of 65 mL 1 hr postprandial is within acceptable limits and does not indicate an increased risk for aspiration.
B. Being in a high-Fowler's position (sitting upright) during feedings actually reduces the risk of aspiration.
C. A history of gastroesophageal reflux disease (GERD) predisposes the client to aspiration, as reflux increases the risk that gastric contents may enter the airway.
D. Although a high-osmolarity formula can cause gastrointestinal distress, it is not as directly related to aspiration risk as GERD.
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