Exhibits

The client is at risk of developing
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and
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Answer and Explanation

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

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. "You can apply counterpressure to your back with each position change." Counterpressure is commonly used for pain relief during labor, particularly for back labor caused by fetal positioning. It is not a typical nonpharmacological intervention for post-cesarean pain management.
B. "You should change positions as little as possible." Frequent position changes help promote circulation, prevent complications such as deep vein thrombosis, and reduce stiffness. Encouraging mobility with proper pain management is essential for recovery after a cesarean birth.
C. "You should use patterned-paced breathing when changing positions." Patterned-paced breathing is a technique used during labor for pain management and relaxation. While controlled breathing may help with general discomfort, it is not the most effective strategy for post-cesarean pain during movement.
D. "You can splint the incision with a pillow when changing positions." Holding a pillow against the incision site provides support, reduces strain on the abdominal muscles, and minimizes pain when moving, coughing, or laughing. This is a well-established method for post-cesarean pain relief.

A. Increased urinary output B. Decreased BUN level C. Decreased hemoglobin level D. Increased weight of 0.91 kg (2 lb)

Correct Answer is A

Explanation

A. Increased urinary output. Furosemide is a loop diuretic that promotes diuresis by inhibiting sodium and water reabsorption in the kidneys. Increased urinary output indicates the medication is effectively reducing fluid volume, which is beneficial for clients with heart failure to decrease edema and pulmonary congestion.
B. Decreased BUN level. Blood urea nitrogen (BUN) levels can fluctuate due to hydration status and kidney function, but a decrease in BUN is not a primary indicator of furosemide’s effectiveness. Instead, BUN levels should be monitored for potential elevation, which could indicate dehydration or renal impairment as an adverse effect of the medication.
C. Decreased hemoglobin level. Furosemide does not directly affect hemoglobin levels. A decrease in hemoglobin may indicate anemia, which is not a desired or expected effect of diuretic therapy for heart failure.
D. Increased weight of 0.91 kg (2 lb). An increase in weight suggests fluid retention, which would indicate that heart failure is worsening rather than improving. Effective furosemide therapy should lead to weight reduction due to fluid loss, not weight gain.

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Exhibits The client is at risk of developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is 1 day postoperative following a vaginal hysterectomy. Which of the the following findings should the nurse report to the provider?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

Exhibits

The client is at risk of developing
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