A nurse is assisting with providing care for a client who is in labor.

Exhibits

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated? For each potential intervention, click to specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Encourage frequent ambulation.

Prepare the client for catheterization

Ensure the client maintains a supine position while in bed.

Check FHR every 30 min.

Perform a Nitrazine test.

Check client's temperature every hour.

Obtain CBC blood sample

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.

- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.

- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.

- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.

- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.

- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.

- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Asymptomatic palpitations are generally not a concern during pregnancy. They can be a common and benign experience due to increased blood volume and changes in heart function.
B. Abdominal cramping at 26 weeks of gestation may indicate preterm labor or other complications and should be reported to the provider. Persistent or severe cramping can be a sign of potential issues requiring medical evaluation.
C. Bleeding gums are common due to increased blood flow and hormonal changes in pregnancy. This symptom is usually not serious but should still be monitored.
D. White vaginal discharge is normal during pregnancy and often increases as pregnancy progresses. It is usually not a sign of a problem unless accompanied by other symptoms.
Here’s a detailed answer for each of the s using the specified format:

A. A single crease in the palm B. A notch in the lip C. Extra digits on the hand D. An inversion of the foot

Correct Answer is A

Explanation

A. A single crease in the palm is correct. A single transverse palmar crease (simian line) is a common finding in infants with trisomy 21.
B. A notch in the lip is not a common finding in trisomy 21. This feature is more associated with other conditions like cleft lip or palate.
C. Extra digits on the hand (polydactyly) is not characteristic of trisomy 21. It is more commonly associated with other genetic conditions.
D. An inversion of the foot (clubfoot) is not a specific finding for trisomy 21. While some infants with trisomy 21 might have foot deformities, this is not a defining characteristic.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is collecting data from a client who is at 26 weeks of gestation. Which of the following findings reported by the client should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

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A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?

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A nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?