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 B

Explanation

A. Provide education on oral contraceptives. This is not a priority for treating acute PID, though education on preventing sexually transmitted infections (STIs) that can lead to PID is important.
B. Removal of intrauterine device prior to treatment. This is a priority intervention because an intrauterine device (IUD) can be a source of infection and inflammation, exacerbating pelvic inflammatory disease (PID). Removing it can help reduce infection risk and facilitate treatment.
C. Institute contact precautions. PID is typically not spread by casual contact, so standard precautions are sufficient.
D. Administer acyclovir as ordered. Acyclovir is used to treat viral infections like herpes and is not relevant for bacterial infections like PID, which is usually treated with antibiotics.

A. Establish IV access B. Assess the client's vital signs C. Obtain fetal heart rate D. Perform a sterile vaginal exam

Correct Answer is C

Explanation

A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.

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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

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Correct Answer is B

Explanation

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