A nurse is caring for a 34-year-old female client in the labor and delivery unit.

Exhibits

The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)

Blood pressure of 170/98 mm Hg

Pain rating of 5 out of 10 with each contraction

Variable decelerations lasting 20 seconds

Fetal heart rate of 142 beats/minute with accelerations

Deep tendon reflexes absent

Temperature of 98.6° F (37° C)

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.

Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.

Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.

Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.

Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.

Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.

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Correct Answer is A

Explanation

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

A. Genital warts. B. German measles. C. Syphilis. D. Herpes simplex virus.

Correct Answer is D

Explanation

Choice A rationale

Genital warts, caused by human papillomavirus (HPV), typically present as small, flesh-colored or gray swellings in the genital area. They do not usually cause pain or vesicular lesions like those described. Genital warts may be flat or cauliflower-like in appearance but are generally distinct from the symptoms described in the question.

Choice B rationale

German measles (rubella) is a viral infection characterized by a red rash, mild fever, and swollen lymph nodes. It is not associated with vesicular lesions on the genital area. The virus primarily affects the respiratory system, and symptoms do not typically include shallow vesicles on the pubis, labia, and perineum.

Choice C rationale

Syphilis, caused by the bacterium Treponema pallidum, presents in stages. Primary syphilis manifests as a single sore (chancre), while secondary syphilis involves skin rashes and mucous membrane lesions. Tertiary syphilis can cause severe medical problems. The symptoms described do not align with any syphilis stage but rather suggest a different condition.

Choice D rationale

Herpes simplex virus (HSV) causes painful, shallow vesicles or ulcers in the genital area. HSV lesions are typically small, fluid-filled blisters that can rupture and form ulcers. The client's symptoms of shallow, small vesicles on her pubis, labia, and perineum are indicative of genital herpes.

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A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Correct Answer is A

Explanation

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

Correct Answer is D

Explanation

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A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse evaluates the client’s progress. Review the findings below and determine if each one is normal or abnormal.

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A nurse is caring for a 34-year-old female client in the labor and delivery unit.

Exhibits

The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)