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A nurse is reviewing the medical record of a client who is postpartum and has preeclampsi

Hct 39.6

Serum albumin 4.5 g/dL

WBC 9.000/mm

Platelets 50,000/mm

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Hct 39.6 is incorrect. This hemoglobin level is within a typical range and may not require immediate intervention.

Choice B Reason:

Serum albumin 4.5 g/dL is incorrect. A serum albumin level of 4.5 g/dL is within the normal range and does not suggest an urgent issue.

Choice C Reason:

WBC 9,000/mm³ is incorrect. A white blood cell count of 9,000/mm³ is within the normal range and is not typically a cause for immediate concern in the absence of other symptoms or indications.

Choice D Reason:

Platelets 50,000/mm³ is correct. A platelet count of 50,000/mm³ is significantly below the normal range and may indicate thrombocytopenia, a condition associated with preeclampsi

A. Thrombocytopenia in preeclampsia can lead to bleeding complications and requires close monitoring and management.

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Correct Answer is C

Explanation

A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.

B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.

C. Changes in the cervix are a key sign of true labor.

True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.

D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.

A. Apply fundal pressure B. Prepare to administer oxytocin C. Observe for crowning. D. Observe for the presence of a nuchal cord

Correct Answer is C

Explanation

The correct answer is C. Observe for crowning.

A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.

B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.

C. Observing for crowning is the correct action.

Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.

D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.

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A nurse is reviewing the medical record of a client who is postpartum and has preeclampsi

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is C

Explanation

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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