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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.

Gravida 4: para 3.

Fetal heart rate 136 to 142 beats/minute.

Variable decelerations to 120 beats/minute lasting 20 seconds.

37-weeks, 1-day gestation by 10-week ultrasound.

Pain rating of 5 on 0 to 10 pain scale with each contraction.

Vaginal exam 4 cm dilated, 50% effaced, -3 station.

Contractions every 3 to 4 minutes, moderate to palpation.

A-blood type, received Rh(D) immune globulin.

Answer and Explanation

Correct Answer : A,C,F

Choice A rationale

Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.

Choice B rationale

A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.

Choice C rationale

Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.

Choice D rationale

A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.

Choice E rationale

A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.

Choice F rationale

A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.

Choice G rationale

Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.

Choice H rationale

An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.

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Correct Answer is B

Explanation

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.

A. Yogurt. B. Collard greens. C. Whole milk. D. Strawberries.

Correct Answer is D

Explanation

Choice A rationale

Yogurt is a good source of calcium and protein but is not particularly high in folic acid. It is beneficial for overall health but not the best option for increasing folic acid intake.

Choice B rationale

Collard greens are high in folic acid, but since the client does not like green leafy vegetables, this option is not suitable for her.

Choice C rationale

Whole milk provides vitamin D and calcium, but it is not a significant source of folic acid. It would not effectively help the client meet her increased folic acid needs.

Choice D rationale

Strawberries are a good source of folic acid and can be a suitable option for the client to increase her intake without consuming green leafy vegetables or soy products. .

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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Correct Answer is B

Explanation

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

Correct Answer is D

Explanation

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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.