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 ["A","C","D"]

Explanation

A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.

A. Encourage the client to empty her bladder. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Document the findings and continue to monitor the client.

Correct Answer is D

Explanation

A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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