The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.

Answer and Explanation

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

Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.

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Correct Answer is B

Explanation

A. Leg cramps: Leg cramps are a common and expected discomfort during the later stages of pregnancy. They usually result from changes in circulation, pressure from the growing uterus, or altered calcium and magnesium levels.

B. Blurred vision: Blurred vision is a concerning finding in pregnancy as it can be a sign of preeclampsia, a serious hypertensive disorder that poses risks to both the mother and fetus. It requires immediate evaluation by the provider.

C. Urinary frequency: Urinary frequency is a common symptom in late pregnancy due to the pressure of the enlarging uterus on the bladder. It is typically expected unless accompanied by signs of infection.

D. Gingivitis: Gingivitis can occur during pregnancy due to hormonal changes that affect gum tissue. While it should be managed with good oral hygiene, it is not an urgent concern requiring immediate reporting.

A. Hyperbilirubinemia B. Hyperemesis gravidarum C. Iron deficiency anemia D. Neural tube defects

Correct Answer is D

Explanation

A. Hyperbilirubinemia: Hyperbilirubinemia in neonates is commonly due to immature liver function and the breakdown of red blood cells after birth. It is not linked to maternal folic acid deficiency and would not be prevented through maternal folic acid supplementation.

B. Hyperemesis gravidarum: Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs during pregnancy, affecting the mother rather than the neonate. Folic acid supplementation does not prevent this condition, as it is more related to hormonal changes during pregnancy.

C. Iron deficiency anemia: Iron deficiency anemia occurs when there is an inadequate amount of iron, not folic acid, in the mother’s or infant’s diet. While iron is important during pregnancy for both the mother and the developing fetus, folic acid deficiency primarily affects neural tube development, not iron levels or red blood cell production in the same way. Iron supplementation is recommended during pregnancy to prevent iron deficiency anemia.

D. Neural tube defects: Neural tube defects, such as spina bifida and anencephaly, are directly linked to folic acid deficiency during early pregnancy. Adequate folic acid intake before conception and during early pregnancy significantly reduces the risk of these serious birth defects affecting the brain and spine.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a group of clients about taking recommended folic acid supplements prior to conception and throughout pregnancy as primary prevention. Which of the following conditions can occur in the neonate as the result of folic acid deficiency?

Correct Answer is D

Explanation

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.