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A nurse is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

dark red vaginal bleeding, and abdominal pain

pain a 7 on a scale of 0 to 10

"My blood pressure has been high during the pregnancy."

Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

116/min, minimal variability noted

bilateral breath sounds clear

tearful

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

Rationale:

Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.

Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.

Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.

FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Storing oxygen tanks under the bed is not safe due to limited ventilation and fire hazards.

B. The oxygen gauge should be checked daily, not weekly, to monitor levels.

C. The oxygen tank should be placed away from curtains or drapes to reduce the risk of fire.

D. The oxygen tank wrench should be readily accessible in case of emergencies.

A. Position the client's knees slightly higher than the hips when up in a chair. B. Keep an abduction pillow between the client's legs. C. Raise the head of the client's bed to a high-Fowler's position. D. Elevate the client's affected leg on a pillow when in bed.

Correct Answer is B

Explanation

A. Positioning the knees higher than the hips could increase the risk of hip dislocation.

B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.

C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.

D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.

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Naxlex Comprehensive Predictor Exams

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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