Try Naxlex NCLEX-RN (Free-Trial)

The nurse has reviewed the Vital Signs and Nurses' Notes from 5 weeks ago.

Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again.

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

Client states, "I'm nauseated all the time

I've been a little constipated, but it's not too bad

Abdomen without tenderness on palpation

Bowel sounds hypoactive.

Oral mucous membranes sticky

Also reports they are urinating less and that urine is dark yellow and odorous

No edema

Blood pressure 102/66 mm Hg

Urine noted to be dark yellow and concentrated

Answer and Explanation

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

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "This test should be performed after your baby is 24 hours old.": Newborn genetic screening is ideally performed after 24 hours of life to ensure accurate detection of metabolic and endocrine disorders. Performing the test too early can result in false-negative results due to insufficient accumulation of metabolites in the blood.

B. "A nurse will draw blood from your baby's inner elbow.": Newborn screening is typically performed via a heel stick, not from the inner elbow. The lateral or plantar aspect of the heel provides safe access to capillary blood for accurate testing.

C. "Your baby will be given 2 ounces of water to drink prior to the test.": Newborns are not given water prior to screening. Water administration is unnecessary and could be harmful, as infants should receive breast milk or formula to meet hydration needs.

D. "This test will be repeated when your baby is 2 months old.": While some repeat testing may occur if initial results are inconclusive, routine newborn genetic screening is performed once after 24 hours of life, not automatically repeated at 2 months.

A. Apply splints to the child's extremities during the day. B. Have the child take a tub bath each morning. C. Encourage the child to take naps during the day. D. Keep the child on bedrest as long as pain persists.

Correct Answer is B

Explanation

A. Apply splints to the child's extremities during the day: Splints are typically used at night or as prescribed to prevent contractures and support joints, not during active daytime periods. Daytime use may restrict movement unnecessarily.

B. Have the child take a tub bath each morning: A warm bath helps relieve morning stiffness and joint pain associated with juvenile idiopathic arthritis. The heat promotes muscle relaxation and increased joint mobility, making it easier for the child to engage in daily activities.

C. Encourage the child to take naps during the day: While rest is important, excessive daytime sleep is not a primary intervention for managing joint stiffness or pain. Short rest periods are preferred instead of prolonged naps.

D. Keep the child on bedrest as long as pain persists: Prolonged bedrest can worsen joint stiffness and muscle atrophy. Encouraging gentle movement and activity is important to maintain joint function while managing pain.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?

A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps, placing them in the order of performance. Use all the steps.)

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

A nurse is providing prenatal teaching about iron to a client who follows a vegetarian diet. The nurse should recommend that the client consume which of the following foods to enhance the absorption of nonheme iron?

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take? (Select all that apply.)