Try Naxlex NCLEX-RN (Free-Trial)

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.

A. Soft abdomen B. Heart rate 120/min C. A fetal heart of 150/min with moderate variability D. Painless vaginal bleeding

Correct Answer is B

Explanation

A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn 4 hours after their birth. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?

A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

A nurse is using Naegele's rule to calculate the estimated due date of a client who reports that the first day of their last menstrual cycle was July 21st. Which of the following should the nurse document as the client's expected due date?

A nurse is caring for a newborn Exhibits Complete the sentence below using the list of options The newborn is at highest risk of developing dropdown as evidenced by the newborn’s Blank 2 dropdown

A nurse is caring for a client who is in the fourth stage of labor and received an epidural during labor. Which of the following actions should the nurse take before ambulating the client to the bathroom?

A nurse is reviewing the medical record of a client who is requesting an oral contraceptive for birth control. The nurse should identify which of the following findings as a contraindication for the use of oral contraceptives for this client?

A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

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?