A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation
Select the 5 findings that require follow up by the nurse
Nausea
DTR
Blood pressure
Fetal heart tracing
Weight assessment
Respiratory assessment
Fundal height
Lower extremity assessment
Correct Answer : B,C,E,G,H
A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.
B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Keeping objects in the same place help maintain a safe environment and independence for a client with vision loss.
B. When caring for a client with vision loss, the nurse should avoid approaching the client from the side since it may startle them.
C. Providing high-wattage lighting can improve visibility for clients with partial vision loss. Adequate lighting reduces shadows and enhances contrast, making it easier for the client to see their surroundings
D. Allowing extra time for tasks helps orient them to the nurse's presence and facilitates communication.
E. While gentle touch can be a way to announce presence, it is better to verbally announce oneself first to avoid startling the client, particularly if they are not expecting contact.
Correct Answer is A
Explanation
A. Newborn genetic screening is typically performed after 24 hours of age to ensure accurate results and allow for the detection of certain genetic conditions.
B. Newborn genetic screening is typically performed only once, shortly after birth, and is not routinely repeated at 2 months of age.
C. Newborn genetic screening does not typically require the baby to drink water prior to the test.
D. While blood is drawn from the baby for genetic screening, it is typically obtained from the baby's heel, not the inner elbow.
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