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A nurse is caring for a client at 39 weeks gestation

Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Vital Signs

1130

Oral temperature 38.3 C (101 F )

Heart rate 98min

Respiratory rate 18/min

Blood pressure 112/59 mm Hg

Oxygen saturation 98% on room air

Nurses Notes

1130

Client states, ‘I think my water broke. The pad under me is soaked’. Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 mins moderate to palpation. Fetal heart rate is 140/min.

Diagnostic Results

1200

HGB 10 g/dl (greater than 11 g/dl)

HCT 34% (greater that 33%)

WBC 22,000 ( 5,000 – 11,000)

Oral temperature 38.3 C (101 F )

HGB 10 g/dl (greater than 11 g/dl)

Heart rate 98min

Blood pressure 110/60 mm Hg

Uterine contractions every 3 mins moderate to palpation

Answer and Explanation

The Correct Answer is ["A","B"]

Oral temperature 38.3°C (101°F)
Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
HGB 10 g/dL (normal > 11 g/dL)
Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

Heart rate 98/min: Slightly elevated but within normal range for labor.
Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. The car seat should remain rear-facing until at least age 2, or until the child reaches the maximum height and weight limit specified by the manufacturer, not just until 12 months.
B. The retainer (chest) clip should be positioned at the level of the infant's armpits, not the abdomen, to ensure proper restraint.
C. Positioning the car seat at a 45° angle helps keep the infant’s airway open and reduces the risk of aspiration or airway obstruction.
D. For rear-facing seats, the harness straps should be at or below the baby's shoulders, not above.

A. Assist the client to empty their bladder. B. Apply oxygen at 2 L/min via nasal canula. C. Massage the client's fundus. D. Prepare to initiate cardiopulmonary resuscitation.

Correct Answer is D

Explanation

A. Emptying the bladder is not a priority during an amniotic fluid embolism (AFE) emergency.
B. Oxygen at 2 L/min is insufficient; high-flow oxygen or intubation may be necessary.
C. Fundal massage is used to control bleeding, not to treat AFE.
D. An amniotic fluid embolism can cause sudden cardiovascular collapse and respiratory failure; preparing to initiate cardiopulmonary resuscitation (CPR) is critical for survival.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a new guardian about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a new mother about newborn care. Which of the following statements by the client indicates an understanding of the teaching?

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