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The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
The following abnormal laboratory results support the client's preeclampsia diagnosis:
- A. WBC count
- B. Hemoglobin
- C. Serum creatinine
- D. 24-hour urine protein
Correct Answer: D
Rationale: Elevated 24-hour urine protein is a hallmark of preeclampsia, indicating renal involvement.
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The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
The client, gravida 3 para 2, at 38 weeks gestation is admitted at 0700 for induction of labor. Which action is a priority?
- A. Change primary fluids to dextrose 5% in 0.9% sodium chloride
- B. Discontinue the insulin infusion
- C. Obtain a capillary blood glucose level
- D. Perform a cervical examination
Correct Answer: C
Rationale: Checking blood glucose is critical during labor induction to manage gestational diabetes.
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
Which client statement requires immediate follow-up with the health care provider?
- A. Are my feet covered? I cannot feel them anymore.'
- B. I cannot finish my lunch today; my abdomen feels so distended.'
- C. I have been so exhausted since my last chemotherapy treatment.'
- D. When is my next dose of pain medicine? My pain is a 10 out of 10 .'
Correct Answer: A
Rationale: Loss of sensation in the feet suggests worsening spinal cord compression, requiring urgent provider notification.
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Which condition does the nurse suspect?
- A. Acute postinfectious glomerulonephritis
- B. Hemolytic uremic syndrome
- C. Rhabdomyolysis
- D. Urinary tract infection
Correct Answer: A
Rationale: Cola-colored urine, edema, and recent infection point to acute postinfectious glomerulonephritis.
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Which of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.
- A. I will contact the health care provider immediately if my child experiences any vision changes, such as blurriness.'
- B. I will schedule a follow-up visit for a urinalysis and blood pressure check.'
- C. My child may notice small amounts of blood in the urine for several weeks.'
- D. My child should avoid exposure to friends and family who show signs of an upper respiratory infection.'
- E. My child will require lifelong blood pressure medication with frequent monitoring at home.'
Correct Answer: A,B,C,D
Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.
Which of the following findings indicate that the newborn's condition has declined? Select all that apply.
- A. Axillary temperature is 96.3 F (35.7 C) and respirations are 84/min
- B. Blood glucose level is 32 mg/dL (1.8 mmol/L) prior to feeding
- C. Newborn is jittery and has a high-pitched cry
- D. Newborn is turning toward the breast while in skin-to-skin contact with the mother
- E. One wet diaper and no stools are noted since birth
Correct Answer: A,B,C
Rationale: Hypothermia , hypoglycemia , and jitteriness indicate decline, requiring intervention.