Exhibits
The postpartum nurse reviews the nurses' notes to determine if the outcomes were successful.
Click to highlight the notes that demonstrate a positive outcome.
The client is admitted to the hospital after her membranes rupture at 38 weeks gestation. A vaginal examination is done. The nurse determines that the client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor shows that contractions are occurring every 4 minutes and lasting 70 seconds, and the nurse palpates the quality as strong. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L). The client is transferred to the labor-delivery-recovery (LDR) suite. The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate is reassuring with a baseline of 145 and moderate variability The nurse briefly reviews pushing techniques with her and her husband and notifies the obstetrician of the client's progress. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum. The infant weighs 9 lbs. 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes.
Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L)
The client dilates quickly to 10 cm and feels a strong urge to push
The fetal heart rate is reassuring with a baseline of 145 and moderate variability
After three cycles of open-glottis pushing, the baby's head is crowning
The head is born easily over an intact perineum
The infant weighs 9 lbs. 9 oz (4.34 kgs)
Apgar of 7 at 1 minute, then 9 at 5 minutes
The Correct Answer is ["A","B","C","D","E","G"]
Rationale for Correct Findings:
- The client dilates quickly to 10 cm and feels a strong urge to push: Rapid dilation and the strong urge to push indicate that the client is progressing effectively through labor, with no signs of obstruction or delays.
- The fetal heart rate is reassuring with a baseline of 145 and moderate variability: A reassuring fetal heart rate with moderate variability is a good sign that the baby is not experiencing any distress during labor, indicating a healthy fetal condition.
- The head is born easily over an intact perineum: The ease of the baby's head being born over an intact perineum suggests that the delivery is progressing smoothly, with minimal risk of perineal trauma.
- Apgar of 7 at 1 minute, then 9 at 5 minutes: The Apgar scores of 7 at 1 minute and 9 at 5 minutes show a positive outcome in neonatal assessment, with a good recovery.
- The fasting blood glucose (FSBG) is 86 (4.8 mmol/L): A fasting blood glucose of 86 mg/dL is within the normal range (74 to 106 mg/dL), indicating that the client’s blood glucose levels are well-controlled, which is a positive sign for managing her gestational diabetes.
Rationale for Negative Finding:
- The infant weighs 9 lbs. 9 oz (4.34 kgs): Macrosomia (a term used for babies born weighing more than 4 kg) can be associated with gestational diabetes, which increases the likelihood of delivering a larger baby. Macrosomia may lead to potential complications such as shoulder dystocia or increased risk for cesarean delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.
B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.
C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.
D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.
Correct Answer is A
Explanation
A. Observe insertion site: The nurse should assess the suprapubic catheter insertion site for signs of infection, redness, or other complications. This is crucial to ensure the catheter is functioning correctly and to prevent infection.
B. Assess perineal area: The perineal area is not directly related to the suprapubic catheter, as it is inserted into the bladder through the abdomen. The focus should be on the insertion site and the catheter itself.
C. Measure abdominal girth: While measuring abdominal girth could be important if the client has issues such as fluid retention or urinary retention, it is not the primary focus for routine assessment of a suprapubic catheter.
D. Palpate flank area: The flank area may be relevant for kidney assessment, but for a suprapubic catheter, the primary focus should be on the catheter insertion site and its function.
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