Question

A nurse is caring for a client who is at 36 weeks of gestation.

Answer 1

Correct Answers

Liver function tests [ improved ]
Edema [ improved ]
Fetal heart rate and variability [ declined ]
Headache [ improved ]
Epigastric discomfort [ improved ]
Urine dipstick [ not changed ]

Rationale :

🔷 Liver function tests – Improved

🔷 Day 1 labs showed AST 250 U/L, ALT 213 U/L, and bilirubin 30 mg/dL, which are highly elevated, indicating hepatic involvement typical of severe preeclampsia or HELLP syndrome.

🔷 On Day 2, there is a notable decline in liver enzymes and bilirubin levels (AST 113 U/L, ALT 94 U/L, bilirubin 18 mg/dL), indicating improvement in hepatic function.

🔷 The downward trend in these values demonstrates that the client is responding to treatment, particularly magnesium sulfate therapy.

🔷 These lab improvements signal a reduction in systemic inflammation and hepatic strain.

🔶 Edema – Improved

🔶 On Day 1, the client had +3 lower extremity edema and facial edema, signs of fluid retention and vascular permeability due to preeclampsia.

🔶 On Day 2, lower extremity edema decreased to +2, though facial edema remained, indicating partial fluid status improvement.

🔶 This change implies reduced capillary leakage or improved vascular tone.

🔶 Though not completely resolved, the lesser degree of edema represents clinical improvement.

💠 Fetal heart rate and variability – Declined

💠 FHR on Day 1 was 158 bpm with moderate variability and accelerations, showing good fetal oxygenation.

💠 By Day 2, the FHR dropped to the 120s, with minimal variability and no accelerations, indicating possible fetal distress or CNS suppression from worsening maternal status or magnesium.

💠 These non-reassuring signs suggest decreased fetal well-being and warrant prompt evaluation.

💠 The decline in variability and acceleratory patterns represents a deterioration in fetal condition.

🔵 Headache – Improved

🔵 On Day 1, the client reported a severe headache (8/10), a neurological sign of worsening preeclampsia.

🔵 On Day 2, headache intensity decreased to 2/10, showing response to magnesium sulfate and CNS stabilization.

🔵 This change demonstrates reduced cerebral vasospasm or pressure.

🔵 The relief of this symptom reflects a positive neurological response to treatment.

🟣 Epigastric discomfort – Improved

🟣 Epigastric pain was reported on Day 1, a red flag for possible hepatic capsule distension or HELLP syndrome.

🟣 On Day 2, the client denied epigastric pain, showing reduction in liver irritation or swelling.

🟣 The symptom resolution suggests improvement in hepatic inflammation and reduced risk of hepatic rupture.

🟣 This marks clear symptomatic improvement in maternal condition.

⚫ Urine dipstick – Not changed

⚫ On both days, the urine dipstick showed 2+ protein, reflecting persistent proteinuria, a hallmark of preeclampsia.

⚫ The absence of change indicates that renal involvement remains ongoing despite improvement in other symptoms.

⚫ This suggests stable but unresolved kidney pathology, requiring continued monitoring.

⚫ No improvement in this marker implies persistent glomerular permeability.

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Answer 2

Correct Answers

Blank 1 Correct Option: Meconium aspiration syndrome
Blank 2 Correct Option: Meconium-stained fluid noted during labor

Rationale :

✅ Condition: Meconium Aspiration Syndrome (MAS)

🔹 Meconium Aspiration Syndrome occurs when a newborn inhales a mixture of meconium-stained amniotic fluid and amniotic fluid into the lungs either before, during, or immediately after delivery.

🔹 It is most common in post-term infants, especially those delivered at or beyond 41 weeks, due to increased fetal stress and meconium passage.

🔹 Respiratory findings such as expiratory grunting, fine crackles, and rapid, shallow breathing are early signs suggestive of MAS.

🔹 The presence of green-stained vernix and fingernails, and meconium-stained fluid are red flags that support this diagnosis.

🔹 If aspirated, meconium can block airways, cause inflammation, and lead to respiratory distress, hypoxemia, or pulmonary hypertension.

🔹 Early identification and intervention are essential to reduce complications like pneumonia or persistent pulmonary hypertension of the newborn (PPHN).

✅ Client Finding: Meconium-stained fluid noted during labor

🔹 Meconium in the amniotic fluid indicates that the fetus experienced some intrauterine stress, such as hypoxia, prompting passage of meconium before delivery.

🔹 It is a significant risk factor for meconium aspiration, especially if the infant gasps or breathes in utero or during initial cries.

🔹 In this case, green-stained vernix and fingernails confirm exposure to meconium, supporting the risk of aspiration.

🔹 The newborn is post-term (42 weeks), further elevating the risk because meconium passage is more common in overdue pregnancies.

🔹 Although the Apgar scores are high, the respiratory signs (grunting, crackles) suggest developing compromise that aligns with early MAS.

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Answer 3

Correct Answers:

Instruct the client to avoid alcohol for 72 hr after treatment.
Administer metronidazole 2 g PO x 1 dose.
Recommend the client's partner receive treatment.

Rationale :

Instruct the client to avoid alcohol for 72 hr after treatment.

🟢 Metronidazole, a common treatment for Trichomoniasis, has a known interaction with alcohol, leading to a disulfiram-like reaction characterized by nausea, vomiting, flushing, and tachycardia.

🟢 Clients must be advised to avoid all alcohol during treatment and for at least 72 hours after the last dose to prevent this reaction.

🟢 Educating the client on this interaction is a standard precaution when prescribing this medication.

🟢 Failure to comply can result in unpleasant and dangerous side effects that can lead to ER visits or treatment non-compliance.

Administer metronidazole 2 g PO x 1 dose.

🟡 The client presents with frothy, yellow-green, malodorous vaginal discharge, vaginal inflammation, dyspareunia, and dysuria, which are classic signs of Trichomoniasis, a protozoal STI.

🟡 The first-line treatment is oral metronidazole 2 g in a single dose, which is both effective and convenient.

🟡 NAAT and culture will confirm diagnosis, but based on the clinical presentation, empirical treatment is often initiated.

🟡 This therapy provides rapid symptom resolution and prevents ongoing transmission.

Recommend the client's partner receive treatment.

🔵 Trichomoniasis is a sexually transmitted infection, and re-exposure is likely if partners are not treated simultaneously.

🔵 CDC guidelines recommend treating all sexual partners, even if they are asymptomatic, to prevent reinfection and further spread.

🔵 Partners are often given the same oral metronidazole regimen.

🔵 Partner treatment is essential for infection control and public health safety.

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Answer 4

Correct Answers

Blank 1 Correct Option: Antiviral medication
Blank 2 Correct Option: Perineal lesions

Rationale :

✅ A: Antiviral medication

🔹 The client presents with small, painful vesicles and pustules on the labia majora, which are classic findings in genital herpes simplex virus (HSV) infection—most commonly caused by HSV-2.

🔹 These lesions typically appear as clusters of vesicles or ulcers with clear drainage, and are often preceded by systemic symptoms like chills, muscle aches (myalgia), and localized discomfort.

🔹 The painful lesion stage is often followed by a phase of crusting and healing, but the virus remains dormant in nerve ganglia and can reactivate periodically.

🔹 First-line treatment includes antiviral therapy, such as acyclovir, valacyclovir, or famciclovir, to reduce symptom severity, shorten lesion duration, and decrease viral shedding.

🔹 Early treatment also helps minimize transmission risk and promotes faster lesion resolution.

✅ B: Perineal lesions

🔸 The client’s physical examination findings of pinpoint open vesicles and pustules with clear drainage are textbook signs of an active herpes simplex outbreak.

🔸 Although the client denies current pain, localized discomfort during sitting and mild vaginal itching are consistent with herpetic irritation and inflammation.

🔸 These perineal lesions, especially with the history of systemic symptoms like chills and myalgia, strongly support HSV as the underlying condition.

🔸 Visual diagnosis is often supported by viral culture or PCR, but in symptomatic cases, treatment is often initiated empirically.

🔸 The lesion appearance—grouped vesicles on an erythematous base—makes herpes the most probable etiology over bacterial causes.

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Answer 5

Correct Answers:

"I'll make sure his diaper is loose in the front."
"I'll expect the plastic ring to fall off by itself within a week."
"I'll call the doctor if I see any bleeding."

Rationale :

"I'll make sure his diaper is loose in the front."

🔷 Loose diapering is essential after circumcision to minimize pressure or rubbing against the healing site.

🔷 The Plastibell device sits at the tip of the penis and should remain undisturbed to fall off naturally.

🔷 A tight diaper can cause pain, inflammation, or premature dislodgement of the ring.

🔷 Loose fitting also promotes airflow and healing and reduces the chance of adhesions or irritation.

"I'll expect the plastic ring to fall off by itself within a week."

🔶 The Plastibell ring is designed to fall off on its own—usually between 5 to 8 days.

🔶 It works by cutting off circulation to the foreskin tissue, causing it and the ring to separate naturally.

🔶 Parents should be advised not to pull or attempt to remove the ring, as this can cause bleeding or trauma.

🔶 Monitoring for signs of infection or delayed separation (after 8–10 days) is also advised.

"I'll call the doctor if I see any bleeding."

🟡 Bleeding after circumcision should be minimal and easily controlled with gentle pressure.

🟡 If bleeding continues, soaks the diaper, or recurs, it may indicate a complication such as infection, improper healing, or vessel involvement.

🟡 Promptly notifying the provider allows for early medical intervention, preventing worsening outcomes.

🟡 Additional red flags to report include discharge, odor, swelling, fever, or if the ring hasn’t fallen off after 10 days.

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Answer 6

Correct Answers:

Cerebral manifestations
Blood pressure
Gastrointestinal assessment findings

Rationale :

Cerebral manifestations

🔹 The client reports a headache persisting for several days that has now become more severe (5/10) and is accompanied by dizziness when standing.

🔹 These are neurologic (cerebral) signs that may indicate increasing central nervous system irritability, a hallmark feature of worsening preeclampsia.

🔹 Although the client denies visual disturbances, the worsening headache and dizziness still warrant immediate provider notification, as they may precede seizures (eclampsia).

🔹 Early detection of cerebral symptoms is critical in preventing serious maternal complications.

Blood pressure

🔸 The client has elevated BP readings: 156/90 mm Hg at 0900 and 160/96 mm Hg at 1000, both of which meet criteria for mild to severe hypertension in pregnancy.

🔸 Persistent blood pressure readings ≥140/90 mm Hg after 20 weeks of gestation suggest gestational hypertension or preeclampsia.

🔸 BP ≥160 systolic or ≥110 diastolic are thresholds for severe features and require prompt intervention.

🔸 Timely provider notification is essential to initiate lab work, fetal monitoring, or magnesium sulfate therapy if preeclampsia with severe features is confirmed.

Gastrointestinal assessment findings

🟢 The client reports “heartburn”, which may actually reflect epigastric pain—a classic symptom of liver involvement in severe preeclampsia or HELLP syndrome.

🟢 In pregnancy, true epigastric pain related to preeclampsia is due to hepatic swelling or irritation, and often mistaken for indigestion or reflux.

🟢 This symptom, especially when combined with headache and edema, should be taken seriously and immediately communicated to the provider for evaluation.

🟢 It may signal impending eclampsia or liver damage, which requires immediate lab work (LFTs, platelets) and potential hospital admission.

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Answer 7

Correct Answers:

6

Rationale :

✅ Heart Rate: The newborn's heart rate is 110 beats per minute, which is above 100. This earns a score of 2 points, indicating a healthy pulse.

✅ Respiratory Effort: The newborn has a slow, weak cry, which reflects irregular or weak breathing. This condition is scored as 1 point.

✅ Muscle Tone: The infant shows some flexion of extremities, but not active motion. This reduced tone receives a score of 1 point.

✅ Reflex Irritability: The newborn grimaces in response to suctioning of the nares. A grimace without coughing or crying scores 1 point.

✅ Color: The body is pink, but the extremities are blue (acrocyanosis), which is normal in many newborns immediately after birth. This appearance earns 1 point.

🔹 Total Apgar Score = 2 (heart) + 1 (respiratory) + 1 (tone) + 1 (reflex) + 1 (color) = 6

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Answer 8

Correct Answers:

5.3

Rationale :

✅ Step 1: Convert pounds to kilograms

28 lb ÷ 2.2 = 12.73 kg

✅ Step 2: Calculate the dose in mg

10 mg × 12.73 kg = 127.3 mg

✅ Step 3: Calculate how many mL to administer

The available concentration is 120 mg in 5 mL.

Set up the proportion:

127.3 mg ÷ 120 mg = 1.061

Then:

1.061 × 5 mL = 5.3 mL

✅ Final Answer:

5.3 mL

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Answer 9

Correct Answers:

"As a nurse, I am required by law to report suspected child abuse."

Rationale :

🔹 Nurses are mandated reporters, which means they are legally obligated to report any suspected cases of child abuse or neglect to the appropriate authorities.

🔹 This responsibility is part of the nurse’s role to protect vulnerable populations, such as children, and ensure safety and early intervention.

🔹 The nurse’s response must be honest, professional, and non-defensive, focusing on their legal and ethical duty, not on assigning blame.

🔹 This answer provides a direct explanation without breaching confidentiality or deflecting accountability.

🔹 It supports transparency while maintaining the integrity of the nurse’s role in child welfare.

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Options	improved	not changed	declined
Liver function tests
Edema
Fetal heart rate and variability
Headache
Epigastric discomfort
Urine dipstick

Custom NIJR209 Final ASSESSMENT SP-2024

No.

1 :
A nurse is caring for a client who is at 36 weeks of gestation.

Correct Answers

🔶 Edema – Improved

2 :
A nurse is caring for a newborn who is 30 min old.

Correct Answers

3 :
A nurse in a gynecology office is caring for a client.

Answer Options

4 :
A nurse is caring for a client.

Correct Answers

5 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

6 :
A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

Answer Options

8 :
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

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Custom NIJR209 Final ASSESSMENT SP-2024

No.

1 : A nurse is caring for a client who is at 36 weeks of gestation.

Correct Answers

🔶 Edema – Improved

2 : A nurse is caring for a newborn who is 30 min old.

Correct Answers

3 : A nurse in a gynecology office is caring for a client.

Answer Options

4 : A nurse is caring for a client.

Correct Answers

5 : A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

6 : A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

Answer Options

8 : A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

9 : A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

1 :
A nurse is caring for a client who is at 36 weeks of gestation.

2 :
A nurse is caring for a newborn who is 30 min old.

3 :
A nurse in a gynecology office is caring for a client.

4 :
A nurse is caring for a client.

5 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

6 :
A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

8 :
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?