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A nurse is assisting in the care of a client on a labor and delivery unit.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "Droplet precautions require that I wear a gown and gloves when providing client care." Droplet precautions require wearing a surgical mask when within three feet of the client, but gowns and gloves are only needed if direct contact with secretions is expected. Incorrect PPE use can lead to inadequate protection or unnecessary resource use. Understanding specific precaution types ensures proper infection control.
B. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20." Blood spills should be cleaned using a 1:10 bleach solution, not 1:20, to ensure effective decontamination. A stronger bleach concentration eliminates bloodborne pathogens like HIV and hepatitis B. The solution should be applied to the spill and left to sit before wiping. Using an incorrect dilution reduces disinfection effectiveness.
C. "Soiled dressings should be placed in a biohazard trash receptacle." Soiled dressings contain bodily fluids and potential pathogens, so they must be disposed of in a biohazard waste container. Regular trash does not provide adequate containment and increases the risk of contamination. Proper disposal protects healthcare workers and the environment from infection. Adhering to these protocols ensures compliance with infection control standards.
D. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub." Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores, requiring handwashing with soap and water. The mechanical action of scrubbing is necessary to remove spores from the hands. Proper hand hygiene reduces transmission risks in healthcare settings. Infection control protocols emphasize soap and water for C. difficile prevention.

A. Use a moisturizing soap to clean the skin around the client's stoma. B. Change the client's ostomy appliance 1 hr after breakfast. C. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. D. Empty the client's ostomy pouch before removing the skin barrier.

Correct Answer is D

Explanation

A. Use a moisturizing soap to clean the skin around the client's stoma. Using moisturizing soap is not recommended because it can leave a residue that interferes with the adhesion of the skin barrier. A mild, non-moisturizing soap should be used to cleanse the area, followed by thorough rinsing and drying.
B. Change the client's ostomy appliance 1 hr after breakfast. Changing the ostomy appliance should ideally be done when the stoma is less active, which is usually before meals or several hours after meals. Changing it right after breakfast may lead to difficulty managing output if the stoma is still active.
C. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. The skin barrier opening should be cut to fit the stoma snugly, typically 1/8 inch (0.3 cm) larger than the stoma size, not 0.5 inches. A larger opening can lead to skin irritation and leakage.
D. Empty the client's ostomy pouch before removing the skin barrier. This is an important step to minimize the risk of spills and make the process more manageable. Emptying the pouch ensures that the contents do not leak out during the change, helping maintain a clean and safe environment during the procedure.

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A nurse is assisting in the care of a client on a labor and delivery unit. Exhibits Which of the following findings require further evaluation by the nurse? Select all that apply.

Nursing Test Bank

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Explanation

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A nurse is assisting in the care of a client on a labor and delivery unit.

Exhibits

Which of the following findings require further evaluation by the nurse?

Select all that apply.