The nurse is assisting in the care of the client who is at 30 weeks of gestation.

Nurses' Notes

1200:

Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.

Encouraged client to cough and take deep breaths regularly.

Assisted with insertion of 18-gauge IV and initiation of IV fluid.

Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.

FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.

1400:

Magnesium sulfate infusion ongoing.

Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.

Urine output 20 mL in the last hour

1405:

Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.

1800:

Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally

Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.

Select the findings that indicate the client's condition has improved.

Urine output 40 mL in the last hour

Temperature 38.3°C(101 F)

Blood pressure 146/96 mm Hg

Deep tendon reflexes 2+ bilaterally

Heart rate 78/min

Answer and Explanation

Correct Answer : D,E

Deep tendon reflexes (DTR): At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.

Heart rate: At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.

Other findings:

Urine output 40 mL in the last hour: Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.

Temperature 38.3°C (101°F): This indicates a fever, which is not a sign of improvement.

Blood pressure 146/96 mm Hg: Although this is better than a severely hypertensive reading, it is still elevated.

Nursing Test Bank

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Correct Answer is B

Explanation

The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.

A. Have the child take a tub bath each morning B. Apply splints to the child's extremities during the day. C. Encourage the child to take naps during the day. D. Keep the child on bedrest as long as pain persists.

Correct Answer is A

Explanation

Correct answer:

A. Have the child take a tub bath each morning: Warm tub baths are recommended for children with juvenile idiopathic arthritis (JIA) as they help to relieve joint stiffness and pain, especially in the morning. The warm water can soothe the joints, making movement easier and reducing discomfort throughout the day.

Why the other options are less appropriate:

B. Apply splints to the child's extremities during the day: While splints may be used in JIA, they are typically applied during the night (resting splints) to maintain joint position and prevent contractures. Daytime use of splints (working splints) may be considered in certain situations, but generally, children are encouraged to be as active as possible during the day to maintain joint mobility.

C. Encourage the child to take naps during the day: While rest is important, encouraging too much rest during the day may contribute to joint stiffness. Regular activity helps maintain joint function and mobility, which is essential in managing JIA.Frequent daytime naps also interfere with the child's quality of sleep.

D. Keep the child on bedrest as long as pain persists: Prolonged bedrest is not recommended for children with JIA. It can lead to muscle atrophy, increased stiffness, and reduced joint mobility. Instead, the focus should be on maintaining activity within the child's pain tolerance and using pain management strategies.

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Other findings:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

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