A nurse is caring for a client in the labor and delivery unit.

Complete the following sentence by using the list of options

The client is at great risk for developing

as evidenced by the

.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for correct choices

• chorioamnionitis: The client’s fever, malodorous vaginal discharge, and tachycardia indicate intra-amniotic infection, making chorioamnionitis the strongest risk. Nitrazine-positive discharge with odor further supports infectious etiology rather than labor-only changes. These findings align with hallmark signs of chorioamnionitis in term pregnancy.

• Temperature: A maternal temperature of 38.7° C demonstrates systemic inflammatory response and is a key diagnostic criterion for intra-amniotic infection. Fever combined with localized vaginal changes increases the likelihood of infection within the amniotic cavity. This makes elevated temperature the most appropriate evidence for the selected risk.

Rationale for incorrect choices

• Abruption placenta: Abruption typically presents with painful bleeding, uterine rigidity, or fetal distress, which are absent here. The client’s symptoms instead center on infection indicators rather than placental separation. No hemodynamic instability or abdominal pain consistent with abruption is reported.

• urinary tract infection: Although leukocyte esterase is positive, the client’s primary symptoms—fever, malodorous discharge, nitrazine-positive fluid—point toward reproductive tract infection rather than urinary involvement. The urinalysis lacks nitrites or other strong evidence of a bacterial UTI. These findings are less consistent than those for chorioamnionitis.

• Contraction patterns: Frequent contractions occur in normal labor progression and do not specifically indicate infection. There is no abnormal uterine activity pattern linked to chorioamnionitis risk. Therefore, contraction pattern does not serve as the defining evidence for this condition.

• Fetal heart rate: A normal baseline FHR of 140/min does not signal infection or distress. Fetal tachycardia would be expected if the fetus were affected by maternal infection, but it is not present here.

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Correct Answer is B

Explanation

A. Cleansing the insertion site daily: Frequent cleansing of an epidural insertion site is not recommended because excessive manipulation increases the risk of infection. Standard practice is to keep the site clean and dry, assessing it regularly without daily cleaning unless contamination occurs.

B. Covering the insertion site with a transparent dressing: Using a sterile, transparent dressing allows continuous visualization of the insertion site for early signs of infection, leakage, or inflammation. It protects the site while permitting ongoing assessment, which is essential for clients receiving epidural analgesia.

C. Administering supplemental opioids as needed: Supplemental opioids should be used cautiously in clients with epidural analgesia because they can increase the risk of respiratory depression and sedation. Pain management should primarily rely on the epidural infusion and follow prescribed protocols rather than routine PRN systemic opioids.

D. Replacing the infusion tubing every 72 hr: Epidural infusion tubing typically should be replaced according to institutional protocol, often every 24 hours, not 72 hours, to reduce the risk of infection. Extending tubing changes beyond recommended intervals increases the likelihood of contamination and catheter-related complications.

A. The availability of religious facilities B. Influenza incidence rates for the current year C. The leading cause of death for the prior year D. Individual perceptions about how residents interact

Correct Answer is A

Explanation

A. The availability of religious facilities: A windshield survey involves direct observation of the community environment. Observing resources such as religious facilities, schools, parks, and stores provides information about community assets, social support, and infrastructure, which are key factors in assessing community health.

B. Influenza incidence rates for the current year: Incidence rates require access to public health records or databases, not visual observation. This type of epidemiological data is collected through statistical reports, not a windshield survey.

C. The leading cause of death for the prior year: Mortality data are obtained from health department statistics or vital records. This information cannot be gathered through direct community observation and therefore is not part of a windshield survey.

D. Individual perceptions about how residents interact: Perceptions and attitudes require interviews, surveys, or focus groups. A windshield survey captures observable, physical, and environmental characteristics, not subjective opinions, so this information would need other data collection methods.

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A nurse is caring for a client in the labor and delivery unit. Complete the following sentence by using the list of options The client is at great risk for developing ______________ as evidenced by the ______________.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?

Correct Answer is B

Explanation

A community health nurse is preparing to collect data to study the health of a local community. The nurse should plan to obtain information about which of the following factors during a windshield survey?

Correct Answer is A

Explanation

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Exhibits A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is caring for a client in the labor and delivery unit.

Complete the following sentence by using the list of options

The client is at great risk for developing

as evidenced by the

.