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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Measure vital signs.

Obtain human chorionic gonadotropin levels.

Collect urine sample for urinalysis.

Recommend bed rest.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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Correct Answer is D

Explanation

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

A. Shallow and irregular respirations. B. Respiratory rate of 50 breaths per minute. C. Flaring of the nares. D. Abdominal breathing with synchronous chest movement.

Correct Answer is C

Explanation

Choice A rationale

While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.

Choice B rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.

Choice C rationale

Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

Correct Answer is D

Explanation

During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Correct Answer is C

Explanation

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?