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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation

Exhibits

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

Answer and Explanation

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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Correct Answer is C

Explanation

A. This task pertains more to secondary prevention, which aims to detect and treat HIV early through screenings and interventions.
B. This task is related to primary prevention, which aims to prevent HIV transmission through education and immunizations.
C. Tertiary prevention focuses on managing and reducing the impact of a disease or condition to prevent complications and promote quality of life. Using an electronic

messaging system to remind clients to take medications aligns with tertiary prevention by helping to manage HIV and prevent disease progression.
D. This task is more aligned with primary prevention, focusing on promoting healthy behaviors to prevent HIV transmission and disease development.

A. A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F) B. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities

Correct Answer is C

Explanation

A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.

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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation Exhibits Select the 5 findings that require follow up by the nurse

Nursing Test Bank

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A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation

Exhibits

Select the 5 findings that require follow up by the nurse