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 A
Explanation
A. This position prevents stomach juice from going into the lungs. Elevating the head helps prevent reflux of stomach contents into the trachea and lungs, which can lead to aspiration pneumonia.
B. This position allows food to be easily digested by the stomach. The position primarily focuses on respiratory protection, not digestion.
C. This position helps my baby breathe better by opening the lungs. While elevation can aid breathing, it's primarily to prevent aspiration rather than improving respiratory function.
D. This position keeps pressure off the stomach. It's not primarily about relieving pressure but rather preventing aspiration.
Correct Answer is ["B","C","E"]
Explanation
A. Chronic fatigue. While chronic fatigue can occur in muscular dystrophy due to muscle weakness, it is not a direct side effect of corticosteroids.
B. Weight gain: Corticosteroids commonly cause weight gain due to increased appetite and fluid retention.
C. Mood changes: Mood swings and changes in behaviour are well-documented side effects of corticosteroid use.
D. Weight loss. Corticosteroids typically cause weight gain rather than weight loss.
E. Osteoporosis: Long-term use of corticosteroids can lead to decreased bone density and osteoporosis, making bone fractures more likely.
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