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Question: 69 of 70
A nurse is caring for a newborn.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Nurses’ Notes
1730:
Physical exam:
General: active with strong cry
HEENT: mucous membranes moist
Respiratory: respirations are shallow and irregular
Cardiovascular: S,S₂, no murmur
Musculoskeletal: moves all extremities well and flexed posture
1830:
Physical exam:
General: active with high-pitched cry
HEENT: mucous membranes moist
Respiratory: respirations are shallow and irregular
Cardiovascular: S, S₂, no murmur
Musculoskeletal: increased muscle tone with tremors noted
upon stimulation
Reflexes: positive Babinski, exaggerated Moro, palmar present
me kemang.00.30: PAUSE Pause Remaining: 00:05:00
Drag words from the choices below to fill in each blank in the following
sentence.
The nurse should further evaluate respiratory charactenistics
Target 2 and muscle tone
is experiencing a complication.
Word Cholces
heart ra⑆o
cry characteristics
Babinski regex
Moro renex
to determine if the newborn
Vital Signs
1730:
Heart rate 144/min
Respiratory rate 48/min
Temperature 37.6° C (98.6° F)
1830:
Heart rate 158/min
Respiratory Rate 72/min
Temperature 37.5° C (99.6° F)
A nurse is caring for a newborn.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Admission Assessment
1700:
Drag words from the choices below to fill in each blank in the following
sentence.
The nurse should further evaluate Target
Target and Targe
Infant born via normal spontaneous vaginal delivery at 38 weeks
of gestation. Apgar score is 8 at 1-minute, 9 at 5-minute.
Weight 2.78 kg (6 lb 2 oz)
is experiencinga complication.
Word Choices
muscle tane
heart rata
cry characteristics
respiratory
characteristics
Babinski reбex
Moro reflex
to determine if the newborn
CONTINUE
Mother’s History and Physical
Prenatal History:
Reports no prenatal care.
Medical History: none
Social History:
Reports using opioids a few times during pregnancy. Recent use
2 days ago. Reports no alcohol or tobacco use.
Nurses’ Notes
1730:
Physical exam:
General: active with strong cry
HEENT: mucous membranes moist
Respiratory: respirations are shallow and irregular
Cardiovascular: S,S₂, no murmur
Musculoskeletal: moves all extremities well and flexed posture
1830:
Physical exam:
General: active with high-pitched cry
HEENT: mucous membranes moist
Respiratory: respirations are shallow and irregular
Cardiovascular: S,, S₂, no murmur
Musculoskeletal: increased muscle tone with tremors noted
upon stimulation
Reflexes: positive Babinski, exaggerated Moro, palmar present
EXRNO EXRIDIt
Vital Signs
Blood pressure 158/97 mm Hg
Heart rate 101/min
Respiratory rate 20/min
Oral temperature 36.8° C (98.2° F)
A nurse is caring for a client who is at 33 weeks of gestation.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Physical Examination
Deep tendon reflexes 3+, negative clonus
Headache
Circumorbital edema
Blurred vision
2+ pitting peripheral edema
FHR 150/min
Question: 68 of 70 Time Remaining: 00:36:17
Pause Remaining: 00:05:00 PAUSE
A nurse is caring for a client who is at 33 weeks of gestation.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Diagnostic Results
Proteinuria 3+, straw-colored urine
Platelet count 150,000/mm³ (150,000 to 400,000/mm³)
BUN 18 mg/dL (10 to 20 mg/dL)
The nurse is assessing the client 24 hr later. How should the nurse interpret
the findings?
For each finding, click to specify whether the finding is unrelated to the
diagnosis, an indication that the client’s condition is improving or an
indication that the client’s condition is worsening.
Findings 24 hr
later
Unrelated to
diagnosis
Sign of potential
improvement
Sign of potential
worsening
condition
Hematuria
Platelet count
90,000/mm³
Leukorrhea
BUN 40 mg/dL
Proteinuria 2+
Positive clonus
CONTINUE
