In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Reference Range:

Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]

Hematocrit of 28% (0.28 volume fraction).

Heart rate of 92 beats per minute.

Systolic murmur.

Elevated thyroid hormone level.

Answer and Explanation

The Correct Answer is A

A)   Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B)   Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C)   Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D)   Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.

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Free Nursing Study Resources

Correct Answer is ["400"]

Explanation

To calculate the mL/hr rate for the infusion pump, we can use the following formula: mL/hr = (Total volume to be infused in mL) / (Time in hours)

In this case, the total volume to be infused is 200 mL, and the infusion time is 30 minutes, which is equal to 0.5 hours.

mL/hr = 200 mL / 0.5 hours mL/hr = 400 mL/hr

Therefore, the nurse should program the infusion pump to deliver 400 mL/hr.

A. Remain non-judgmental and assure the client of confidentiality. B. Provide counseling that most contraceptives protect against infection. C. Clarify that all STIs are transmitted through sexual intercourse. D. Inform the client that complications will not result from reinfection.

Correct Answer is A

Explanation

It is essential for the nurse to maintain a non-judgmental and supportive attitude when caring for clients with STIs, including genital herpes. Assuring the client of confidentiality helps to create a safe and trusting environment, encouraging open communication about the client's concerns and experiences.

This approach promotes the client's well-being and allows for effective education and support regarding STI prevention, transmission, and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["400"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide

Correct Answer is A

Explanation

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

What age-related factors may factor into this client's wound healing? Select all that apply.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

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