A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit.

Complete the following sentence by using the list of options.
The nurse should identify that
__
and _
are findings that require follow-up.

Answer and Explanation

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

The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up.

Rationale for correct answers:
Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery.

Rationale for incorrect answers (Response 1 options):
Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation.

Rationale for incorrect answers (Response 2 options):
Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale

A single dose of the rubella vaccine is typically sufficient to confer immunity. A second dose is not routinely recommended after postpartum administration. The primary goal is to prevent congenital rubella syndrome in future pregnancies by ensuring the mother develops adequate antibody titers to the virus.

Choice B rationale

The rubella vaccine contains live attenuated virus, which carries a theoretical risk of congenital rubella syndrome if the vaccine virus crosses the placenta during pregnancy. Therefore, clients are advised to avoid conception for at least 1 to 3 months, commonly stated as 4 months, after vaccination to minimize any potential fetal exposure.

Choice C rationale

The rubella immunization typically provides long-lasting immunity. It is not necessary to receive an additional rubella immunization during the first trimester of a subsequent pregnancy. Antibody titers are usually maintained, protecting against future rubella infection and subsequent fetal harm.

Choice D rationale

The rubella vaccine is considered safe for breastfeeding mothers and their infants. The live attenuated virus is not shed in breast milk in significant amounts that would pose a risk of infection to the infant. Therefore, breastfeeding can continue without interruption after rubella immunization.

A. Teach the client patterned breathing techniques. B. Encourage the support person to perform effleurage. C. Encourage the support person to apply sacral counterpressure. D. Teach the client to use guided imagery.

Correct Answer is C

Explanation

Choice A rationale

Patterned breathing techniques involve conscious control of respiratory rate and depth, which can redirect attention and promote relaxation. This cognitive distraction reduces the perception of pain by engaging higher cortical centers, thus modulating pain signals transmitted via the spinothalamic tracts. However, it does not directly address the localized pressure associated with back labor.

Choice B rationale

Effleurage involves light, circular stroking of the abdomen. This gentle cutaneous stimulation activates large-diameter afferent nerve fibers, which, according to the gate control theory of pain, can inhibit the transmission of noxious stimuli by smaller-diameter fibers in the spinal cord. While soothing, it may not provide sufficient counter-pressure for intense back labor.

Choice C rationale

Sacral counterpressure involves applying firm, sustained pressure to the sacrum. This technique directly opposes the pressure exerted by the fetal occiput against the sacral nerves during back labor. The deep pressure stimulates mechanoreceptors, which can significantly reduce the perception of pain through afferent inhibition and potentially alter the biomechanics of fetal descent.

Choice D rationale

Guided imagery involves directing the client to focus on pleasant mental images to divert attention from pain. This cognitive behavioral strategy can activate descending inhibitory pathways from the brainstem, releasing endogenous opioids and serotonin, thereby modulating pain perception. However, it may not be as effective for the specific, intense pressure of back labor.

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A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that ____________ and ___________ are findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is ["B","D"]

Explanation

A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?

Correct Answer is C

Explanation

A nurse is collecting a blood phenylketonuria (PKU) test for a newborn prior to discharge. The newborn's guardian asks the nurse what a positive PKU test would mean. Which of the following statements should the nurse make?

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A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?

A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

A nurse is admitting a client who is at 39 weeks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to take?

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A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit.

Complete the following sentence by using the list of options.
The nurse should identify that
__
and _
are findings that require follow-up.