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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. slight yellow vaginal discharge: Gonorrhea often presents with a purulent or yellowish vaginal discharge in females. It is one of the common symptoms along with pelvic pain and dysuria.
B. Decrease in urinary frequency: Gonorrhea can actually increase urinary frequency or cause dysuria. A decrease in frequency is not typical for gonorrhea.
C. frothy, white vaginal discharge: This is more characteristic of Trichomoniasis, not gonorrhea. Gonorrhea usually presents with a thicker, more purulent discharge.
D. low grade fever for three (3) days: While fever can be associated with many infections, it is not a common primary symptom of gonorrhea in the absence of more specific symptoms like discharge or pelvic pain.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}
Explanation
1st Trimester (Conception-13 weeks)
- Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.
2nd Trimester (14-26 weeks)
- Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.
3rd Trimester (27-40 weeks)
- Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
- Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
- Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
- Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.
Finding |
1st Trimester Conception-13 weeks |
2nd Trimester 14-26 weeks |
3rd Trimester 27-40 weeks |
Gender can be determined |
☐ |
☒ |
☐ |
Surfactant production |
☐ |
☐ |
☒ |
Sucking occurs |
☐ |
☐ |
☒ |
Fetus has a heartbeat |
☒ |
☐ |
|
Fetal respiratory movements begin |
☐ |
☐ |
☒ |
Increase in body fat |
☐ |
☐ |
☐ |
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