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Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends. Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Nurses Notes and Flow Sheet

Respiratory

Respirations 16 breaths/minute

Oxygen saturation of 89%

Several deep breaths

Integumentary

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Circulatory

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 mL/hr

Genital/Urinary

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Respirations 16 breaths/minute

Oxygen saturation of 89%

Several deep breaths

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 mL/hr

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Answer and Explanation

The Correct Answer is ["B","C","E","H","J","K"]

Rationale for Correct Choices:

Oxygen saturation of 89%: An oxygen saturation of 89% is below the normal range (95-100%), indicating hypoxemia. This requires immediate follow-up as it suggests inadequate oxygenation, which could be due to respiratory or circulatory complications.
Several deep breaths suggest the patient is trying to compensate for the low oxygen levels by increasing her tidal volume, which may be a sign of respiratory distress or insufficient oxygenation.
Blood pressure 90/62 mm Hg: A drop in blood pressure from the previous reading (102/72 mm Hg) to 90/62 mm Hg could indicate hypovolemia, possibly due to blood loss. This warrants immediate attention to assess the cause, particularly in the context of the client’s risk for hemorrhage.
Pad is saturated with blood: A saturated pad in 15 minutes indicates excessive blood loss, which is concerning for postpartum hemorrhage. This finding requires prompt assessment to manage and treat any ongoing bleeding and prevent further complications.
Boggy fundus 1 cm above umbilicus: A boggy fundus is a sign of uterine atony, where the uterus fails to contract effectively, leading to excessive bleeding. Immediate intervention, such as fundal massage, is needed to help the uterus contract and reduce the risk of hemorrhage.
Fundus rotated to the right: A fundus that is rotated to the right, along with being boggy, suggests the possibility of a full bladder or retained products of conception, both of which can prevent proper uterine contraction and contribute to hemorrhage.

Rationale for Incorrect Choices:

Respirations 16 breaths/minute: A respiratory rate of 16 breaths/minute is normal (12-20 breaths/min) and not indicative of respiratory distress, so this finding does not require immediate follow-up.
Episiotomy intact with no redness: The episiotomy site appears intact, with no redness or signs of infection. This is a positive finding and does not require immediate follow-up.
18 gauge IV to left forearm: An 18-gauge IV is appropriate for fluid administration, and there are no issues with the IV site. This does not need further attention at this time.
Heart rate 96 beats/minute: A heart rate of 96 beats/minute is slightly elevated but not concerning by itself. It can be considered within normal postpartum variation and does not require immediate follow-up.
IV infusing at 125 mL/hr: The IV rate of 125 mL/hr is appropriate for hydration. There are no concerns related to fluid intake or infusion rate, so no immediate action is needed.
Voided 200 mL of clear yellow urine: The client has normal urine output (200 mL of clear yellow urine), indicating good kidney function and fluid balance. There are no concerns with the urinary system.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Ask the husband to step out: Removing the husband may not be necessary, as providing emotional support is important. The husband can help comfort the client, and their presence may offer reassurance during the active phase of labor.

B. Have delivery table set up: With the client at 9 cm dilated, contracting every 2 minutes, and a fetal heart rate of 120 beats/minute, she is nearing the second stage of labor. Preparing the delivery table ensures readiness for delivery, which is the appropriate response to the progression of labor.

C. Administer a PRN narcotic: Since the client is in the active phase of labor with minimal cervical dilation left and experiencing significant pain, administering a narcotic is not advisable at this point, as it may interfere with her ability to push and could potentially affect the baby’s well-being.

D. Notify rapid response team: While the client is in pain, the situation described does not indicate immediate life-threatening concerns for either the mother or baby. The nurse's priority is to prepare for delivery rather than calling a rapid response team.

A. Inform her that a repeat alpha fetoprotein (AFP) should be evaluated. B. Reassure the client that the AFP results are likely to be a false reading. C. Discuss options for intrauterine surgical correction of congenital defects. D. Explain that a sonogram should be scheduled for definitive results.

Correct Answer is D

Explanation

A. Inform her that a repeat alpha fetoprotein (AFP) should be evaluated: While a repeat AFP test may be necessary, the next step is typically a sonogram to confirm or rule out any abnormalities, as an ultrasound provides more definitive information.
B. Reassure the client that the AFP results are likely to be a false reading: Although false-positive results are possible, it is important not to prematurely reassure the client without confirming the diagnosis through further testing, such as a sonogram.
C. Discuss options for intrauterine surgical correction of congenital defects: It is premature to discuss surgical interventions before confirming whether there is actually a congenital defect. The priority is obtaining further diagnostic information through a sonogram.
D. Explain that a sonogram should be scheduled for definitive results: A sonogram is the next appropriate step after an elevated AFP level, as it provides more definitive information to assess fetal development and determine if there are any abnormalities, such as neural tube defects.

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Body System	Nurses Notes and Flow Sheet
Respiratory	Respirations 16 breaths/minute Oxygen saturation of 89% Several deep breaths
Integumentary	Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm
Circulatory	Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 mL/hr
Genital/Urinary	Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A client at 18 weeks gestation was informed this morning that she has an elevated alpha fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. Which information should the nurse provide?

Correct Answer is D

Explanation

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