A nurse is caring for a 25-year-old female client in an antepartum unit.

Exhibits

For each assessment finding, click to specify if the finding is consistent with preterm labor or preterm prelabor rupture of membranes. Each client finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row

Note: Each category must have at least one response option selected.

Vaginal discharge

Cervical effacement

Low backache

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

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Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

A. A positive finding indicates the inability to metabolize galactose. B. A positive finding indicates the infant will have a slow metabolism. C. A positive finding indicates an inability to metabolize certain amino acids. D. A positive finding indicates an increased risk for neurological anomalies.

Correct Answer is C

Explanation

Choice A rationale

A positive finding for galactosemia, not PKU, indicates the inability to metabolize galactose. Galactosemia is a different metabolic disorder that requires a separate dietary intervention.

Choice B rationale

A positive PKU test does not indicate slow metabolism. Instead, it signifies the inability to metabolize phenylalanine, an amino acid.

Choice C rationale

Phenylketonuria (PKU) is a genetic disorder that leads to the inability to break down the amino acid phenylalanine. Without proper management, it can accumulate in the body and cause brain damage and other health issues.

Choice D rationale

A positive PKU test is not directly linked to an increased risk for neurological anomalies in general. The specific issue in PKU is the inability to metabolize certain amino acids, primarily phenylalanine, which can cause neurological damage if untreated. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to obtain a blood specimen from a newborn via a heel stick.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting a blood phenylketonuria (PKU) test for a newborn prior to discharge.The newborn's guardian asks the nurse what a positive PKU test would mean.Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is assessing a client who is in active labor.The client reports back labor pains.Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?

A nurse is assessing a newborn.Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation.Which of the following findings indicates a reactive nonstress test?

A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.Which of the following findings should the nurse expect?

A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.Which of the following actions should the nurse take?

A nurse is caring for a newborn immediately following birth.The newborn has meconium-stained amniotic fluid.Which of the following actions should the nurse take first?

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously.Which of the following adverse effects is the priority for the nurse to report to the provider?

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?