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. A larger-bore needle (usually 18- to 20-gauge) is recommended for blood transfusions to prevent hemolysis and ensure adequate flow rate.
B. Flushing the tubing with 0.9% sodium chloride ensures that it is primed and free from air or any incompatible solutions before starting the blood transfusion.
C. Vital signs should be checked immediately before, during, and after the transfusion to monitor for adverse reactions.
D. Blood transfusions are typically completed over 2 to 4 hours, depending on the clinical context, to reduce the risk of complications.
Correct Answer is B
Explanation
A. The palms of the hands are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
B. Jaundice is characterized by the yellowing of the skin and eyes due to high levels of bilirubin in the blood. In individuals with dark skin, this yellowing may not be as apparent on the skin itself, making the sclera a more accurate site for assessment.
C. The shoulders are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
D. The face is less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
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