Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.

A. Eat 1 g/kg of protein per day. B. Consume foods high in potassium. C. Take magnesium hydroxide for indigestion. D. Drink at least 3 L of fluid daily.

Correct Answer is A

Explanation

A. For clients receiving hemodialysis, maintaining adequate protein intake is essential because dialysis can remove protein from the blood. The recommended intake is typically about 1 g/kg/day, which helps replace losses and supports overall health.
B. Consume foods high in potassium. Clients with chronic kidney disease often need to restrict potassium intake due to impaired kidney function and the risk of hyperkalemia.
C. Take magnesium hydroxide for indigestion. Clients with chronic kidney disease should avoid magnesium-containing antacids due to the risk of magnesium accumulation and toxicity.
D. Drink at least 3 L of fluid daily. Fluid intake usually needs to be restricted in clients undergoing hemodialysis because their kidneys cannot effectively remove excess fluid, which can lead to complications like hypertension and pulmonary edema.

View Question and Answer

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

Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

The nurse reviews the client's test results Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A charge nurse is concerned about a recent increase in facility-acquired catheter Infections. Which of the following actions should the nurse take first?

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

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