The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?
O negative blood type
Blood pressure 144/94 mm/Hg in left arm
Positive rubella serum antibody titer
Copious leukorrhea
The Correct Answer is B
A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. Circumoral cyanosis. This can occur but is less specific for PDA and more related to general issues with oxygenation.
B. Tachycardia. PDA can lead to increased heart rate as the heart works harder to manage the increased blood flow.
C. Elevated diastolic blood pressure. PDA usually causes a decrease in diastolic pressure, not an increase.
D. Bradycardia. Bradycardia is not typically associated with PDA.
E. Bounding peripheral pulses. PDA allows more blood to flow into the systemic circulation, leading to stronger pulses.
F. Continuous murmur. PDA typically causes a continuous "machine-like" murmur because of the continuous flow of blood from the aorta to the pulmonary artery.
G. Narrow pulse pressure. PDA often causes a wide pulse pressure, not a narrow one.
Correct Answer is D
Explanation
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.