The nurse is continuing to care for the client.

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Deep tendon patellar reflex

Heart rate

Blood pressure

Edema

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Rationale:

• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.

• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.

• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.

• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.

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Free Nursing Study Resources

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

Explanation

Rationale:

A. Thrombocytopenia: Low platelet count is not a recognized risk factor for neonatal hypoglycemia. While it may indicate other hematologic concerns, it does not directly affect the infant’s glucose regulation.

B. Hypothermia: Hypothermia increases metabolic demand and glucose consumption in newborns, making them more susceptible to hypoglycemia. Maintaining neutral thermal environment is crucial to reduce this risk.

C. Maternal diabetes: Infants of mothers with diabetes are at increased risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the high insulin levels can cause a rapid drop in blood glucose.

D. Prematurity: Premature infants have limited glycogen stores, immature liver function, and impaired gluconeogenesis, all of which increase the risk of hypoglycemia. Monitoring and early feeding are essential.

E. Anemia: While anemia can affect oxygen delivery, it is not a direct risk factor for hypoglycemia in the newborn. It may complicate overall neonatal status but does not independently cause low blood glucose.

A. Administer oxygen via nasal cannula at 2 L/min. B. Place the client in a knee-chest position. C. Assist the client to the bathroom. D. Give 500 mL bolus of lactated Ringer's.

Correct Answer is D

Explanation

A. Administer oxygen via nasal cannula at 2 L/min: Oxygen may support maternal and fetal oxygenation, but it does not treat the underlying cause of hypotension following spinal anesthesia. It is a supportive measure, not the first-line intervention.

B. Place the client in a knee-chest position: This position is not recommended for treating hypotension due to spinal anesthesia. The priority is to improve perfusion through fluid resuscitation and positioning that enhances venous return, such as left lateral tilt.

C. Assist the client to the bathroom: Ambulation is unsafe for a client experiencing hypotension after spinal anesthesia and could worsen hypotension or cause falls. The client should remain supine or in a safe position until blood pressure is stabilized.

D. Give 500 mL bolus of lactated Ringer's: Administering a rapid IV fluid bolus is the first-line intervention for hypotension related to spinal anesthesia. It increases intravascular volume, improves venous return, and helps restore blood pressure to maintain maternal and fetal perfusion.

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Naxlex Comprehensive Predictor Exams

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

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

Explanation

A nurse is caring for a client who is in labor, just received spinal anesthesia, and is experiencing hypotension. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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