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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 A

Explanation

A. Disorientation. Temporary confusion and disorientation are common immediately after electroconvulsive therapy (ECT). This occurs due to the brief, induced seizure affecting brain activity. Clients may also experience short-term memory impairment, but orientation typically improves within minutes to hours.
B. Paresthesias. Abnormal sensations such as tingling or numbness are not expected effects of ECT. While muscle soreness may occur due to seizure activity, paresthesias are not a typical post-procedure finding.
C. Sleep apnea. ECT does not cause sleep apnea. However, clients with pre-existing sleep apnea may require careful monitoring due to anesthetic agents used during the procedure, which could temporarily depress respiratory function.
D. Tonic-clonic seizures. ECT induces a controlled seizure lasting about 30 to 60 seconds, but spontaneous seizures should not occur afterward. If a client experiences an unprovoked seizure post-ECT, further evaluation is needed to rule out underlying neurological conditions.

A. Positive Chvostek's sign B. Hypotension C. Confusion D. Positive Babinski reflex

Correct Answer is A

Explanation

A. Positive Chvostek's sign. Hypocalcemia increases neuromuscular excitability, leading to involuntary twitching of facial muscles when the facial nerve is tapped. This sign is a well-known indicator of calcium deficiency and reflects heightened nerve sensitivity.
B. Hypotension. While severe hypocalcemia can affect cardiovascular function, hypotension is not a primary or consistent finding. More commonly, calcium imbalances affect muscle contractions rather than directly causing low blood pressure.
C. Confusion. Hypocalcemia can cause neurological symptoms, but confusion is more common in severe or prolonged cases. Early manifestations are usually neuromuscular, such as tetany or muscle cramps, rather than cognitive impairment.
D. Positive Babinski reflex. This reflex is associated with upper motor neuron dysfunction and neurological disorders rather than electrolyte imbalances like hypocalcemia. Calcium deficiency primarily affects peripheral nerves and muscle excitability.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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.

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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.