The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?

O negative blood type

Blood pressure 144/94 mm/Hg in left arm

Positive rubella serum antibody titer

Copious leukorrhea

Answer and Explanation

The Correct Answer is B

A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.

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Correct Answer is ["B","C","E"]

Explanation

A. Stand directly in front of the client when talking: Standing directly in front of an agitated client can be seen as confrontational and might escalate the situation. It is better to stand at an angle and maintain a non-threatening posture.
B. Avoid wearing necklaces during client care: Wearing necklaces or other loose accessories can pose a safety risk if a client becomes aggressive and tries to grab or pull them, potentially causing injury.
C. Provide immediate verbal feedback for escalating behavior: Immediate feedback can help de-escalate potentially aggressive behavior by addressing issues before they become more serious. It also reinforces appropriate behavior and sets clear boundaries.
D. Bring security with you for all client interactions: Bringing security for all interactions is impractical and can create an atmosphere of distrust. Security should be involved only when there is a credible risk of violence.
E. Review the layout of the facility: Understanding the layout of the facility, including exits and potential hazards, helps in planning for safe interactions and knowing escape routes if a situation escalates.

A. Ensuring that the client takes care of their ADLS to prevent dependence. B. Ensuring that the client environment is safe to prevent injury. C. Ensuring that the client receives food they like to prevent anxiety. D. Ensuring that the client meets the other patients to prevent social isolation.

Correct Answer is B

Explanation

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

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The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?

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Naxlex Comprehensive Predictor Exams

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