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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. COPD: Clients with chronic obstructive pulmonary disease (COPD) are at increased risk for pneumonia due to compromised lung function, chronic inflammation, and decreased mucociliary clearance, making it easier for pathogens to infect the lungs.

B. Hypertension: While hypertension is a significant cardiovascular risk factor, it does not directly increase the risk of pneumonia. Therefore, it is not a relevant factor in this case.

C. Dermatitis: Dermatitis is a skin condition and does not affect lung function or immunity in a way that would increase the risk of pneumonia.

D. Smoking history: Smoking damages the respiratory epithelium and impairs the immune defenses of the lungs, making smokers more susceptible to respiratory infections such as pneumonia.

E. Type 2 diabetes mellitus: Diabetes compromises immune function and increases the risk of infections, including pneumonia, due to hyperglycemia impairing neutrophil function and other immune responses.

F. Hypothyroidism: While hypothyroidism may cause some general symptoms such as fatigue, it does not directly compromise respiratory function or immunity in a way that increases the risk of pneumonia.

A. Chest x-ray B. 12-lead ECG C. Serum potassium D. PT and INR

Correct Answer is B

Explanation

A. A chest x-ray is important to assess pneumonia but is not the priority when chest pain suggesting a cardiac event is present.

B. A 12-lead ECG is the priority to assess for myocardial ischemia or infarction, given the client’s description of chest pain.

C. Serum potassium is important for cardiac health but not the immediate priority in this scenario.

D. PT and INR are relevant for coagulation but do not address the immediate concern of potential myocardial infarction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in the emergency department (ED) is admitting a client. Exhibits The nurse is reviewing the client's medical record. Which of the following conditions should the nurse identify as a risk factor for pneumonia? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?

Correct Answer is B

Explanation

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