The nurse continues to care for the client.
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
|
Assessment |
Findings |
|
Nurses' Notes |
Client reports lower back pain as 0 on a scale from 0 to 10 No reports of vaginal discharge Membranes are intact. No uterine contractions noted. FHR baseline 138/min, minimal variability. No further reports of burning with urination. |
|
Vital Signs |
Temperature 37.1° C (98.7° F) Blood pressure 120/76 mm Hg |
|
Laboratory Results
|
WBC count 12,000/mm3 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm) |
Client reports lower back pain as 0 on a scale from 0 to 10
No reports of vaginal discharge
No uterine contractions noted.
FHR baseline 138/min, minimal variability.
No further reports of burning with urination.
Temperature 37.1° C (98.7° F)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
The Correct Answer is ["A","B","C","E","F","G"]
Rationale for correct choices
• Client reports lower back pain as 0 on a scale from 0 to 10: Resolution of back pain suggests that uterine contractions and associated discomfort have decreased, indicating reduced preterm labor activity and improved comfort. Pain control and labor suppression interventions appear effective.
• No further reports of burning with urination: The absence of dysuria indicates that a possible urinary tract infection is improving, either spontaneously or following interventions such as increased hydration or antibiotic therapy. Symptom resolution reflects clinical improvement.
• No uterine contractions noted: The absence of contractions indicates that preterm labor activity has decreased. This reflects effective management and a positive trend in preventing progression to preterm birth.
• Temperature 37.1° C (98.7° F): A normalized temperature reflects a reduction in maternal infection or inflammatory response. This indicates that the client’s fever is resolving, decreasing risk for maternal and fetal complications.
• No reports of vaginal discharge: The absence of abnormal vaginal discharge suggests that cervical or infection-related changes are resolving, reflecting decreased risk of preterm labor progression
• WBC count 12,000/mm³: The white blood cell count has decreased from the initial 16,000/mm³, showing a positive response to antibiotic therapy. A decrease from the previous elevated WBC count indicates that infection or inflammation is resolving, demonstrating laboratory improvement and decreased maternal risk.
Rationale for incorrect choices
• FHR baseline 138/min, minimal variability: A baseline fetal heart rate within normal limits is reassuring, but minimal variability persists, indicating continued need for monitoring. This alone does not indicate full clinical improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm compromises safety by preventing timely notification if the client attempts to get out of bed unassisted. Bed alarms should remain active at all times for clients on fall precautions.
B. Establish an elimination schedule for the client: Scheduling regular toileting reduces the risk of falls by minimizing unassisted trips to the bathroom, which are a common cause of falls, especially in clients with mobility or cognitive impairments. This is an effective and preventive intervention.
C. Allow the client to walk unassisted near the nursing station: Clients on fall precautions should not ambulate without assistance or appropriate safety measures, even near the nursing station, as unassisted walking increases the risk of falls.
D. Raise all four bed rails on the client's bed: Raising all four bed rails can increase the risk of injury if the client attempts to climb over them and is generally considered a restraint, which requires careful assessment and provider authorization.
Correct Answer is D
Explanation
A. Increase intake of milk products: Many clients with irritable bowel syndrome (IBS) have lactose intolerance or worsened gastrointestinal symptoms with dairy consumption. Increasing milk products could exacerbate bloating, cramping, and diarrhea.
B. Increase intake of foods high in gluten: Gluten can trigger symptoms in some clients, especially those with IBS or non-celiac gluten sensitivity. Increasing gluten intake is not recommended and may worsen abdominal discomfort and bloating.
C. Sweeten foods with fructose corn syrup: Fructose and high-fructose corn syrup can worsen IBS symptoms, causing gas, bloating, and diarrhea. Clients should avoid foods high in fructose to minimize gastrointestinal discomfort.
D. Consume foods high in bran fiber: Soluble fiber, such as that found in bran, can help regulate bowel movements and reduce constipation in IBS. Increasing intake of fiber-rich foods is a safe and effective dietary strategy to manage symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.