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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.
Correct Answer is C
Explanation
A. To prevent infection and ensure proper healing, it's usually advised to avoid submerging the catheterization site in water until it has adequately healed.
B. There is generally no need for a special diet such as a clear liquid diet following cardiac catheterization unless specified for other reasons.
C. Following cardiac catheterization, it's important to keep the pressure dressing in place to ensure proper healing and prevent bleeding from the catheterization site. Typically, the dressing is removed the next day under safe, controlled conditions.
D. Typically, children can return to school within a few days after cardiac catheterization unless complications arise or there are other specific medical advisories.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.