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Exhibits

Click to highlight the findings that indicate an improvement in the client’s condition.

Nurses Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted

Temperature 38° C (100.4° F)

Heart rate 88/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

Answer and Explanation

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

Client rates pain with contractions as a 3 on a scale of 0 to 10: The client previously rated pain as 8/10 before epidural placement. The new rating of 3/10 indicates that the epidural was effective. Adequate pain control contributes to maternal relaxation and labor progression.
FHR 150/min with moderate variability: This shows fetal well-being, as moderate variability indicates a well-oxygenated and neurologically intact fetus. Previously, the FHR showed minimal variability with decelerations, so this marks clear improvement.
Accelerations present, no decelerations noted: Accelerations in the FHR are reassuring and associated with fetal movement and adequate oxygenation. Absence of the prior variable decelerations shows resolution of cord compression or stress.
Heart rate 88/min, respiratory rate 16/min, BP 122/80 mm Hg: These vital signs are within expected ranges, reflecting stable maternal status. Her heart rate has normalized from 104/min, and no signs of respiratory compromise or hypotension are present.
Rationale for Incorrect Choices:
Temperature 38°C (100.4°F): Although mild, this low-grade fever may signal early signs of infection such as chorioamnionitis, especially in a patient with meconium-stained fluid. It is not considered a definitive improvement.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place the client in restraints:Restraints are a last-resort intervention and should only be used when the client poses an immediate danger to self or others and less restrictive methods have failed. Initiating restraints first violates the client’s rights and can escalate agitation.

B. Escort the client to a place of seclusion:Seclusion, like restraints, is a restrictive intervention that should only be used after less invasive strategies have been attempted. Removing a client without consent may also worsen their aggression or fear.

C. Offer the client PRN medication:While medication may be helpful in calming the client, it should not be the first step unless the client is in imminent danger or past strategies have failed. Attempting non-pharmacologic interventions first respects the client’s autonomy.

D. Offer the client choices for a diversionary activity:This is the least restrictive intervention and a therapeutic first approach. Providing the client with options promotes autonomy, can redirect aggression, and helps prevent escalation through calming, client-centered communication.

A. Scaly plaques on skin B. Pearly papules with a central crater C. Weeping skin surfaces D. Irregularly shaped, pigmented papules

Correct Answer is C

Explanation

A. Scaly plaques on skin: Scaly plaques are more characteristic of chronic conditions like psoriasis, not Stevens-Johnson syndrome. SJS is an acute, severe mucocutaneous reaction involving widespread epidermal necrosis, not thick, scaly lesions.

B. Pearly papules with a central crater: This describes basal cell carcinoma, a form of skin cancer. It is not consistent with the acute, inflammatory, and blistering nature of Stevens-Johnson syndrome, which typically involves mucous membranes and skin detachment.

C. Weeping skin surfaces: Stevens-Johnson syndrome leads to widespread skin blistering, sloughing, and erosion, often resulting in moist, weeping lesions. This breakdown of the epidermis resembles a severe burn and is a hallmark of the condition.

D. Irregularly shaped, pigmented papules: These are often associated with melanoma or other pigmented skin disorders. They do not match the blistering, painful rash and mucosal involvement seen in SJS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is displaying combative behavior. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client who has developed Stevens-Johnson syndrome. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing a seizure while in bed. Which of the following actions should the nurse take?

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?

A nurse is teaching a community class about treating heat exhaustion. Which of the following instructions should the nurse Include?

A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

A case manager is performing a home visit for a client following a stroke. The client's partner is providing care in the home. The client's partner states that she sometimes feels exhausted. Which of the following referrals should the case manager recommend for the caregiver?

A nurse is preparing to administer ceftriaxone via continuous IV Infusion to a client who has pelvic inflammatory disease. When preparing the infusion, the nurse should identify which of the following diluents as incompatible with this medication?

A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to see first?

A nurse is teaching a client who had a myocardial infarction about continuing to exercise after discharge. Which of the following statements by the client indicates an understanding of the teaching?