The nurse is continuing to care for the client.

Nurses' Notes.

Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.

headache unrelieved by acetaminophen.

Client also reports.

urinary frequency and decreased fetal movement.

Client is a G3. P2 with one preterm birth.

Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.

+3. pitting edema in bilateral lower extremities.

Patellar reflex 4+. without the presence of clonus.

Client reports occasional.

nighttime leg cramps.

Reports three fetal movements within the.

last 30 min.

External fetal monitor applied with a baseline FHR.

140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

Vital Signs.

Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.

Respiratory rate 16/min.

BP 162/112 mm Hg. Oxygen saturation 979% on room air.

Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.

Respiratory rate 18/min.

BP 166/110 mm Hg. Oxygen saturation 999% on room air.

Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with.

preeclampsia or HELLP syndrome.

Each finding may support more than one.

disease process.

Platelet count

Hemoglobin

Alanine aminotransferase (ALT)

Blood pressure

Answer and Explanation

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

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale:

The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.

Choice B rationale:

The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.

Choice C rationale:

The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.

Choice D rationale:

The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.

A. "Take your temperature within 30 minutes after your first morning void." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature every night before going to bed." D. "Take your temperature immediately after waking and before getting out of bed." .

Correct Answer is D

Explanation

Choice A rationale:

Taking temperature within 30 minutes after the first morning void is specific to ovulation prediction kits, not the basal body temperature method.

Choice B rationale:

Taking temperature 1 hour after getting out of bed is not accurate for tracking basal body temperature fluctuations related to the menstrual cycle.

Choice C rationale:

Taking temperature every night before going to bed does not provide consistent basal body temperature readings, as the body temperature needs to be taken at the same time every morning to detect subtle changes related to the menstrual cycle.

Choice D rationale:

This is the correct answer. To use the basal body temperature method effectively, the client should take their temperature immediately after waking and before getting out of bed every morning. This helps in detecting the slight rise in basal body temperature that occurs after ovulation, indicating the fertile period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving change-of-shift report for a group of clients.Which of the following clients should the nurse plan to assess first?

Correct Answer is C

Explanation

A nurse is teaching a client about family planning using the basal body temperature method.Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has heart failure.Which of the following manifestations should the nurse expect?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is reinforcing teaching with a group of adolescents about safety.Which of the following information should the nurse include in the teaching?

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations.Which of the following actions should the nurse include in the plan?

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis.Which of the following actions should the nurse take?

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.Which of the following examples should the nurse include in the teaching as an example of malpractice?

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting daily insulin for blood glucose management.The nurse should anticipate administering which of the following types of insulin?