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A nurse in an obstetrics clinic is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

Heart rate 110/min

Respiratory rate 18/min

Blood pressure 104/66 mm Hg

Temperature 36.6° C (97.9° F)

Oxygen saturation 99% on room air

Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

WBC count 7,500/mm3 (5,000 to 10,000/mm3)

Hgb 10.2 g/dL (11 to 16 g/dL)

Hct 45% (33% to 47%)

Platelets 360,000/mm3 (150,000 to 400,000/mm3)

Sodium 136 mEq/L (136 to 145 mEq/L)

Potassium 3.3 mEq/L (3.5 to 5 mEq/L)

BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

Appearance clear (clear)

Color dark amber (pale yellow amber)

pH 7.9 (4.6 to 8)

Protein 4 mg/dL (0 to 8 mg/dL)

Specific gravity 1.045 (1.005 to 1.03)

Leukocyte esterase negative (negative)

Nitrites none (none)

Heart rate 110/min

Blood pressure 104/66 mm Hg

Hemoglobin 10.2 g/dL

Potassium 3.3 mEq/L

BUN 28 mg/dL

Urine specific gravity 1.045

Decreased skin turgor

WBC count 7,500/mm3

Client reports vomiting several times a day over the last 2 weeks

Color dark amber

Answer and Explanation

The Correct Answer is ["A","C","D","E","F","G","I","J"]

Heart rate 110/min
Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.
Blood pressure 104/66 mm Hg
Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.
Hemoglobin 10.2 g/dL
Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.
Potassium 3.3 mEq/L
Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.
BUN 28 mg/dL
Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.
Urine specific gravity 1.045
Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.
Decreased skin turgor
Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.
WBC count 7,500/mm3
Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.
Client reports vomiting several times a day over the last 2 weeks
Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.
Urine color dark amber
Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

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Correct Answer is C

Explanation

A. Apply cortisone ointment on the lesions prior to birth:

Cortisone ointment is not appropriate for the treatment of herpes simplex virus (HSV) lesions. Cortisone is a steroid medication that can suppress the immune response, potentially worsening the HSV infection. Additionally, cortisone ointment does not directly treat the virus or prevent its transmission. Therefore, applying cortisone ointment on the lesions would not be effective and could even be harmful to both the mother and the newborn.

B. Administer erythromycin ointment in the newborn's eyes after birth:

Erythromycin ointment is routinely used in newborns to prevent bacterial eye infections, such as those caused by Chlamydia trachomatis or Neisseria gonorrhoeae. However, it is not effective against viruses like HSV. Therefore, while erythromycin ointment is important for preventing bacterial infections in newborns, it does not address the risk of HSV transmission from the mother to the newborn during birth.

C. Anticipate a scheduled cesarean birth:

When a pregnant person has active genital herpes lesions near the time of delivery, a scheduled cesarean section (C-section) is often recommended to reduce the risk of neonatal herpes transmission. Delivering the baby via C-section can decrease the likelihood of the newborn coming into contact with the virus in the birth canal, thereby reducing the risk of neonatal herpes infection. This intervention is specifically targeted at preventing HSV transmission to the newborn and is considered the standard of care in such situations.

D. Initiate IV penicillin G during labor:

Penicillin G is an antibiotic used to treat bacterial infections, but it is not effective against viruses like HSV. Therefore, initiating IV penicillin G during labor would not prevent the transmission of HSV to the newborn. While antibiotics may be used in certain situations during labor to prevent bacterial infections, they do not address the risk of HSV transmission and are not indicated for this purpose.

A. A client who reports lochia rubra requiring changing perineal pads every 3 hr B. A client who reports abdominal cramping during breastfeeding C. A client who has a urinary output of 300 mL in 8 hr D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes

Correct Answer is D

Explanation

. A client who reports lochia rubra requiring changing perineal pads every 3 hr:

This finding is consistent with normal postpartum lochia patterns, particularly in the early postpartum period. Lochia rubra is the initial bright red vaginal discharge that occurs after childbirth, and changing perineal pads every 3 hours is within the expected range. There is no immediate concern requiring notification of the provider for this client.

B. A client who reports abdominal cramping during breastfeeding:

Abdominal cramping during breastfeeding, also known as afterpains, is a common occurrence in the postpartum period, especially for multiparous clients. These cramps are caused by the release of oxytocin during breastfeeding and help the uterus to contract and return to its pre-pregnancy size. While uncomfortable, afterpains are considered normal and do not typically require notification of the provider unless they are severe or accompanied by other concerning symptoms.

C. A client who has a urinary output of 300 mL in 8 hr:

This urinary output is below the expected range for a postpartum client, and it may indicate inadequate fluid intake, urinary retention, or other issues. While it is important to monitor urinary output and address any potential concerns, this finding alone may not require immediate notification of the provider. However, continued monitoring and assessment are warranted to ensure adequate urinary function.

D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes:

Absent deep tendon reflexes are an indication of magnesium toxicity, which is a serious complication of magnesium sulfate administration. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia or eclampsia. However, excessive levels of magnesium can lead to respiratory depression, cardiac arrest, and other adverse effects. Absent deep tendon reflexes are an early sign of magnesium toxicity and require immediate intervention, including discontinuation of magnesium sulfate and close monitoring of the client's respiratory and cardiac status. Therefore, the nurse should notify the provider immediately for further guidance and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

Correct Answer is C

Explanation

A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

Correct Answer is D

Explanation

A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?