Which of the following laboratory tests should the nurse ant...

The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.

Which of the following laboratory tests should the nurse anticipate during the first prenatal visit? Select all that apply.

A. 1-hour glucose tolerance test
B. Group B Streptococcus rectovaginal culture
C. Maternal blood type and screen
D. Sexually transmitted infection screen
E. Urinalysis

Correct Answer: C,D,E

Rationale: First prenatal visit tests include maternal blood type and screen, STI screen, and urinalysis. Glucose tolerance and Group B Streptococcus tests are performed later in pregnancy.

The nurse is caring for a 6-hour-old newborn.
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpOz 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.

Select 2 findings that require immediate feedback?

A. A newborn is brought to the emergency department due to coughing and difficulty feeding.
B. The client was born at home 6 hours ago via spontaneous vaginal birth.
C. With each attempt to breastfeed, the client coughs, vomits, and 'turns blue.'
D. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
E. Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO2 95% on room air.
F. Ballard scoring estimates the client at 37 weeks gestation.
G. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.

Correct Answer: C,E

Rationale: Coughing, vomiting, and cyanosis during feeding indicate potential airway or gastrointestinal issues, such as tracheoesophageal fistula. The elevated respiratory rate (RR 50) suggests respiratory distress, requiring immediate attention.

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

Nurses' Notes
Inpatient - Mental Health Unit
2100:
Client appears anxious and withdrawn, and states, "I am afraid to sleep at night because I get nightmares about my sibling." The client would not elaborate on the content of the nightmares.
1200:
Client attended the first session of cognitive-behavioral therapy.
1300:
Client was observed yelling at peers in the day room because someone changed the television channel. The client is irritable with poor impulse control.
1700: Client appears to be having a panic attack and was found shaking in the room in tears after waking up from a nightmare. The client reports heart palpitations and appears diaphoretic.
Vital signs: P 112/min, RR 20, BP 155/98.

For each of the statements made by the client, click to specify whether the statement indicates that the client's status has improved or not improved.

A. I woke up only once last night.
B. I want to talk about the nightmare I had.
C. I am thinking about selling my car and taking the bus instead.
D. I have been journaling my stressors and emotional reactions to them.
E. Sometimes I still get upset by small issues. but I control my feelings better now.

Correct Answer: A,D,E

Rationale: Statements indicating improvement include waking up less frequently (A), journaling stressors (D), and better emotional control (E). Wanting to talk about nightmares (B) and avoiding driving (C) do not clearly indicate improvement.

The nurse is caring for an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
History and Physical
General
Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees; client reports that these areas itch

Neurological
Alert and oriented to person, place, and time

Eye, Ear, Nose, andThroat (EENT)
Pupils equal, round, and reactive to light and accommodation; client reports no nasal congestion

Pulmonary
Vital signs: RR 34, SpO 92% on room air, airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally; dry, spasmodic cough is noted; no stridor; difficulty speaking in complete sentences

Cardiovascular
Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation; nom murmurs noted; peripheral pulses 2+; capillary refill 3 seconds; no edema

Gastrointestinal
Abdomen soft; bowel sounds normal

Psychosocial
Client appears anxious and is crying, client speaks in short phrases, stating, "left my medicine at a friend's house" and "feels like I can't breathe"; client cannot remember the name of the prescribed home medication; client's parents were notified and are en route to hospital

Progress Notes
0910:
Client's parents were spoken to over the phone. Last evening, the client spent the night at a friend's housewhere some family members smoke cigarettes and have a pet cat that lives in the home.

Medical history:
No accidents or injuries were reported, vaccinations are up to date, mild persistent asthma was diagnosed at age 7, and client has atopic dermatitis.

Allergies: No known allergies.

Family history:
Client is an only child. Parents report having no known medical conditions. Paternal grandfather died of chronic obstructive pulmonary disease, and maternal grandmother has heart disease.

Social history:
Client lives with parents; they do not smoke cigarettes. There are no pets in the client's home.

Current medications:
Beclomethasone inhaler 2 puffs twice a day, albuterol (salbutamol) inhaler 2 puffs
every 4 hours as needed for quick relief of symptoms.

The nurse receives the following prescriptions. Which 3 actions should the nurse prioritize?

A. Administer albuterol (salbutamol) with ipratropium bromide via nebulizer
B. Administer initial dose of PO prednisone once
C. Initiate maintenance IV fluids
D. Initiate NPO status except oral medication
E. Titrate oxygen to achieve an oxygen saturation of >95%

Correct Answer: A,B,E

Rationale: A: Nebulized albuterol and ipratropium are first-line treatments for acute asthma exacerbation to relieve bronchospasm. B: Prednisone reduces inflammation and prevents worsening. E: Titrating oxygen to >95% corrects hypoxia, a critical concern with SpO2 at 92%.

The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.

Select the findings that require immediate follow up.

A. Total abdominal hysterectomy with bilateral oophorectomy and tumor debulking
B. She has had four episodes of vomiting with bilious emesis over the past 12 hours,
C. The client has been receiving broad-spectrum antibiotics since the procedure.
D. The client reports incontinence with coughing or during episodes of vomiting.
E. The abdomen is markedly distended and tenderagogue palpation.

Correct Answer: B,E

Rationale: B: Requires follow-up - Persistent vomiting despite antiemetics suggests a postoperative complication like ileus or obstruction. E: Requires follow-up - Abdominal distension and tenderness indicate potential ileus or obstruction, requiring urgent evaluation. A, C, D: Do not require immediate follow-up as they are expected or less urgent.

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92

For each potential prescription, click to specify whether the prescription is anticipated or not anticipated at this time.

A. Administer propranolol
B. Administer methimazole
C. Perform a pregnancy test
D. Maintain a high-calorie diet
E. Offer moisturizing eye drops
F. Maintain continuous cardiac monitoring
G. Administer thyroid hormone replacement

Correct Answer: A,B,C,D,E,F

Rationale: A: Propranolol is anticipated to manage tachycardia and palpitations. B: Methimazole is anticipated to treat hyperthyroidism by reducing thyroid hormone production. C: A pregnancy test is anticipated due to the absence of menstruation for 3 months, as pregnancy can affect treatment choices. D: A high-calorie diet is anticipated to address weight loss and increased metabolism. E: Moisturizing eye drops are anticipated for exophthalmos-related eye dryness. F: Continuous cardiac monitoring is anticipated due to the high pulse rate (164). G: Thyroid hormone replacement is not anticipated, as the client has hyperthyroidism, not hypothyroidism.