A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hr. Which of the following diagnostic tests should the nurse anticipate?

Speculum exam to test for fetal fibronectin

Amniocentesis to determine fetal lung maturity

Urinalysis to determine protein content

Vaginal swab for nitrazine testing

Answer and Explanation

The Correct Answer is D

A. Fetal fibronectin testing is used to assess risk for preterm labor, not to confirm rupture of membranes.
B. Amniocentesis for fetal lung maturity is generally not needed at 37 weeks or later.
C. Urinalysis is for urinary tract issues, not for detecting amniotic fluid.
D. Nitrazine testing helps determine if vaginal fluid is amniotic fluid by assessing pH, aiding in diagnosing rupture of membranes.

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

Explanation

A. High-pitched, excessive crying is a common sign of neonatal abstinence syndrome (NAS).
B. Tachypnea (rapid breathing) is a typical respiratory symptom of NAS.
C. Body tremors and jitteriness are classic signs of withdrawal in newborns.
D. Newborns with NAS typically exhibit hyperactivity, not extreme lethargy.
E. Reflexes are usually increased (hyperactive), not decreased, in NAS.

A. A client who reports changing their perineal pad every 4 hr. B. A client who has a urine output of 750 mL in 6 hr. C. A client who has 1+ deep tendon reflexes while receiving IV magnesium sulfate. D. A client who reports abdominal cramping pain during breastfeeding.

Correct Answer is C

Explanation

A. Changing a perineal pad every 4 hours is within expected postpartum norms for moderate bleeding. This client’s condition does not indicate an urgent issue.

B. A urine output of 750 mL over 6 hours is adequate (approximately 125 mL/hr) and does not signal immediate concern.

C. Deep tendon reflexes of 1+ in a client receiving IV magnesium sulfate may indicate early magnesium toxicity or impending hyporeflexia. Magnesium sulfate toxicity can lead to respiratory depression and cardiac arrest, making this the highest-priority client.

D. Abdominal cramping during breastfeeding is common due to uterine contractions (afterpains) and is generally expected and non-life-threatening. This can be addressed after assessing higher-priority clients.

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A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hr. Which of the following diagnostic tests should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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