A nurse in an antepartum unit is caring for a client.
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Nurses' Notes
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Client rates pain with contractions as a 3 on a scale of 0 to 10
FHR 150/min with moderate variability. Accelerations present, no decelerations noted
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
The Correct Answer is ["A","B","C","D","E"]
- Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
- Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
- Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
- Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
- FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Findings Consistent with Chorioamnionitis:
- Purulent amniotic fluid
- Fever
Findings Consistent with Preeclampsia:
- Elevated uric acid level
- Decreased platelet count
- Blurred vision
Rationale:
- Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
- Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
- Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
- Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
- Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.
Correct Answer is D
Explanation
A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.
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