A nurse in a provider's office is assessing a client who is at 28 weeks of gestation. Which of the following is an expected finding?
FHR 152/min via Doppler stethoscope
Client reports the absence of fetal movement for the past 8 hr
Client reports cramping and pelvic pressure
Patellar deep tendon reflex 4+
The Correct Answer is A
Choice A reason: A fetal heart rate of 152/min at 28 weeks gestation is within the normal range of 110–160 beats per minute. This is an expected finding and indicates adequate fetal oxygenation and well-being.
Choice B reason: Absence of fetal movement for 8 hours is concerning and not expected. At 28 weeks, fetal movement should be felt regularly. Lack of movement may indicate fetal distress or compromise and requires immediate evaluation.
Choice C reason: Cramping and pelvic pressure at 28 weeks may indicate preterm labor. These are not expected findings and should be promptly reported and assessed to prevent complications.
Choice D reason: A patellar reflex of 4+ indicates hyperreflexia, which is abnormal and may suggest preeclampsia or other neurologic complications. Normal reflexes are 2+. Therefore, this is not an expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hallucinations are a common manifestation of delirium, especially when triggered by acute illness such as fever. Delirium is characterized by disturbances in attention, awareness, and cognition, often accompanied by perceptual disturbances like visual or auditory hallucinations.
Choice B reason: Agnosia, the inability to recognize objects or people, is more commonly associated with neurocognitive disorders such as dementia rather than acute delirium. While delirium affects cognition, agnosia is not a typical finding.
Choice C reason: Bradycardia is not a hallmark of delirium. Delirium is primarily a cognitive and perceptual disturbance, not a cardiac rhythm disorder. Bradycardia would suggest another underlying medical issue.
Choice D reason: Aphasia, a language disturbance, is more characteristic of stroke or other focal neurological disorders. Delirium may cause disorganized speech due to confusion, but not true aphasia.
Correct Answer is D
Explanation
Choice A reason: Serous drainage at the insertion site may indicate mild irritation but does not require discontinuation unless accompanied by signs of infection or infiltration.
Choice B reason: A small air bubble in the tubing is generally harmless and does not require discontinuation. Large air bubbles pose a risk of air embolism, but small ones are typically absorbed without issue.
Choice C reason: Blood return in the tubing indicates that the IV catheter is correctly placed in the vein. This is a normal finding and does not require discontinuation.
Choice D reason: Blanched skin at the insertion site indicates infiltration, meaning IV fluid is leaking into surrounding tissue rather than the vein. This can cause tissue damage and requires immediate discontinuation of the IV to prevent complications.
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