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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Wash the cord daily with mild soap and water. Incorrect because keeping the area dry is crucial; soap can irritate the area.
B. Cover the cord with the diaper. Incorrect because it may trap moisture and cause irritation or infection.
C. Apply petroleum jelly to the cord stump. Incorrect because this may keep the area too moist and prevent it from drying and falling off naturally.
D. Give a sponge bath until the cord stump falls off. This prevents the cord from getting wet, which can increase the risk of infection and delay drying and detachment.

A. Umbilical cord compression B. Fetal head compression C. Uteroplacental insufficiency D. Maternal bradycardia

Correct Answer is C

Explanation

A. Umbilical cord compression. This typically results in variable decelerations, not late decelerations.
B. Fetal head compression. This is usually associated with early decelerations.
C. Uteroplacental insufficiency. Late decelerations occur after the peak of contractions and are indicative of insufficient blood flow and oxygen to the fetus, suggesting a problem with the placenta's ability to provide adequate oxygen.
D. Maternal bradycardia. Maternal bradycardia does not cause fetal decelerations.

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The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?

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