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 D

Explanation

Choice D rationale

Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.

Choice A rationale

Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.

Choice B rationale

Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.

Choice C rationale

Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .

A. Yogurt. B. Collard greens. C. Whole milk. D. Strawberries.

Correct Answer is D

Explanation

Choice A rationale

Yogurt is a good source of calcium and protein but is not particularly high in folic acid. It is beneficial for overall health but not the best option for increasing folic acid intake.

Choice B rationale

Collard greens are high in folic acid, but since the client does not like green leafy vegetables, this option is not suitable for her.

Choice C rationale

Whole milk provides vitamin D and calcium, but it is not a significant source of folic acid. It would not effectively help the client meet her increased folic acid needs.

Choice D rationale

Strawberries are a good source of folic acid and can be a suitable option for the client to increase her intake without consuming green leafy vegetables or soy products. .

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following an amniocentesis, a client verbalizes several concerns.Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

Correct Answer is D

Explanation

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

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 prepares to initiate magnesium sulfate therapy for the client. What is the priority nursing action?

The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

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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)