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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.
Correct Answer is B
Explanation
A. Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.
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