A nurse in an antepartum unit is caring for a client.

Exhibits
Select the 2 findings that require immediate follow-up.

Blood pressure

Fetal heart rate

Fetal station

Characteristics of amniotic fluid

Duration of contraction

Answer and Explanation

Correct Answer : B,D

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

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Correct Answer is D

Explanation

A. Iron supplementation does not have a significant interaction with spironolactone.
B. Magnesium is not contraindicated with spironolactone, though excessive intake should be monitored.
C. Calcium does not pose a major risk when taken with spironolactone.
D. Potassium should be avoided because spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia, a potentially life-threatening condition characterized by cardiac arrhythmias and muscle weakness.

A. Have the client hold their breath during the examination. B. Ensure that the client's bladder is full. C. Instruct the client to bear down when the speculum is inserted. D. Place the client in modified Sims' position.

Correct Answer is C

Explanation

A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.

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A nurse in an antepartum unit is caring for a client. Exhibits Select the 2 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over- the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?

Correct Answer is D

Explanation

A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse in an antepartum unit is caring for a client.

Exhibits
Select the 2 findings that require immediate follow-up.