A nurse is assisting in the care of a client on a labor and delivery unit.
Which of the following findings require further evaluation by the nurse?
Select all that apply.
Report of weight change
Client heart rate
Deep tendon reflexes
Fetal heart rate
Pain rating
Oxygen saturation level
Report of vaginal discharge
Correct Answer : B,D,E,G
A. Report of weight change. A slight weight loss near term is a common finding as the body prepares for labor. This is not an immediate concern.
B. Client heart rate. The heart rate increased from 90/min at 0830 to 110/min at 0845. A rising maternal heart rate could indicate dehydration, pain, or early signs of infection.
C. Deep tendon reflexes. Reflexes are documented as 2+, which is within the expected range and does not indicate hyperreflexia or hyporeflexia.
D. Fetal heart rate. The FHR at 1530 is 120/min with late decelerations, which is concerning. Late decelerations suggest uteroplacental insufficiency, requiring further assessment and possible interventions such as maternal repositioning, oxygen administration, or fluid bolus.
E. Pain rating. The client reports severe back pain rated as 10/10, which may indicate fetal malposition (such as occiput posterior positioning) or rapid labor progression, both requiring evaluation and possible intervention.
F. Oxygen saturation level. The oxygen saturation has remained stable between 96% and 97%, which is within the expected range and does not require immediate intervention.
G. Report of vaginal discharge. An increased amount of blood-tinged discharge at 1530 may indicate cervical dilation or potential complications such as placental abruption, especially in the presence of late decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Ask the provider to spell out the name of the medication. Asking the provider to spell out the name of the medication is important to ensure accuracy and prevent medication errors. This step helps clarify any potential confusion regarding similar-sounding medications or names, reducing the risk of administering the wrong drug.
B. Withhold the medication until the provider signs the prescription. Withholding the medication until the provider signs the prescription is not necessary. Telephone prescriptions are valid and can be administered after being documented appropriately, provided that the nurse follows institutional policies regarding the signing of prescriptions. This means that the nurse should not delay necessary medication administration based on awaiting a signature.
C. Record the date and time of the telephone prescription. Recording the date and time of the telephone prescription is essential for accurate medical documentation. This information is critical for maintaining an accurate medication administration record and for legal purposes, ensuring that there is a clear timeline of the prescription order.
D. Request that the provider confirm the read-back of the prescription. Requesting that the provider confirm the read-back of the prescription is a crucial step in ensuring the accuracy of the prescription. The read-back method helps confirm that the nurse understood the prescription correctly and prevents potential errors by allowing the provider to verify the information relayed.
E. Instruct another nurse to record the prescription in the medical record. Instructing another nurse to record the prescription in the medical record is not appropriate. The nurse who received the telephone prescription should document it to maintain accountability and ensure accurate record-keeping. This promotes responsible practice and avoids miscommunication regarding the prescription details.
Correct Answer is A
Explanation
A. "I've been talking to the baby a lot and haven't told anyone except my mom yet." Talking to the baby suggests emotional attachment and early bonding, which indicates the adolescent is beginning to process and accept the pregnancy. Sharing the news with a trusted individual, like their mother, also suggests they are seeking support.
B. "I don't want to tell my partner in case they don't believe me." Avoiding disclosure due to fear of disbelief suggests uncertainty or anxiety about the pregnancy, which may indicate emotional unpreparedness. Open communication is important for coping and planning.
C. "I've decided to take a break from school and focus on the baby." While prioritizing the baby is important, making major life decisions without exploring available resources may reflect a reactive rather than a well-thought-out approach. Support systems can help balance education and parenting responsibilities.
D. "I don't need to worry about how much I eat now that I'm pregnant." This statement indicates a misunderstanding of nutritional needs during pregnancy. Proper nutrition is crucial for both maternal and fetal health, and disregarding dietary needs may suggest a lack of readiness for the responsibility of pregnancy.
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