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A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol a synthetic prostaglandin E drug. How should the nurse respond?
"You may be at higher risk for having a spontaneous miscarriage."
The nurse adds 20 units of oxytocin to one liter of lactated ringers which should infuse over 6 hours for a client who delivered 2 hours ago. How many ml/hour should the nurse set the infusion pump? (Enter numerical value only.)
1000 ml / 8 hours= 125 ml The pump should run for over 6 hours so 6 + 2 = 8 total hours.
A client receives a prescription for oxytocin 2 milliunits/ min intravenously (IV) for labor augmentation. The IV bag contains oxytocin 20 units in lactated ringers 1 liter. How many ml/ hour should the nurse program the infusion pump to deliver?
1000ml/ 20 units x 1 units/ 1000 mu x 2mu/ min x 60 min/ hour= 120,000/ 20,000= 6 ml/ hr
A client at 38 weeks' gestation presents to the labor and delivery inactive labor. Based on which assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section?
Active herpes lesions on the perineum.
A community health nurse visits a family in which a 16-year-old unmarried daughter is married with her first child and is at 32 weeks' gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? a. Teach the client how to perform pelvic rock exercises and observe for correct feedback b. Determine what physical activities the client has performed in the past 24 hours c. Ask the clients mother to call an ambulance d. Ask the client if she has experienced any recent changes in vaginal discharge
Ask the client if she has experienced any recent changes in vaginal discharge
Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition? A. Early postpartum hemorrhage. B. Laceration on the cervix C. Expected course in the fourth stage of labor. D. A full urinary bladder.
B. Laceration on the cervix
The nurse is preparing to administer methylergonovine maleate to a postpartum client. Based on which assessment finding should the nurse withhold the drug?
Blood pressure 140/90 mmHg
A gravid client comes into the pet department arrives to purchase a pet. Which choice should the nurse instruct the client to avoid?
Cat
An oxytocin induction was started for a gravid client 6 hours ago. When assessing the FHR on the electronic fetal monitor, the nurse notes a "U-shaped" pattern... Which intervention should the nurse implement first?
Change the position of the client.
A newborn with a respiratory rate of 40 breaths/ minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should the nurse take?
Continue to monitor.
The father of a 3-day old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no apparent reason. What information is most important for the nurse to provide this father?
Contract the clinic if the behaviors continue for more than two weeks or become worse.
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first?
Determine current cervical dilation
A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?
Determine current cervical dilation.
A 20-week gestational primigravida who is carrying twins arrives in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
Document the finding in the medical record.
A client who is 14 days postpartum arrives to the clinic for a follow up examination. The nurse is unable to palpate the uterine fundus. Which action should the nurse take.
Document the normal finding.
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/ minute, respiratory rate 16 breaths/ minute, and blood pressure 130/ 74 mm Hg. What action should the nurse implement?
Document these vital signs
A client who is positive for Neisseria gonorrhea vaginally delivered an infant. What medication should the nurse administer?
Erythromycin ointment
While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal which intervention is best for the nurse to implement?
Evaluate the infants suckling reflexes then give the infant to the mother
A client at 31 weeks gestation with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide to the client for the ultrasounds?
Evaluation of fetal growth.
A single woman is scheduled for a thyroid scan using radioactive iodine. She confesses to the nurse that she may be pregnant and plans to have an abortion right away if the pregnancy is confirmed. She insists that the nurse keep this information confidential. What action should the nurse take?
Explain to the client that the procedure will need to be canceled until confirmation is obtained that the client is not pregnant.
A one-week-old full-term infant is readmitted to the newborn nursery for hyperbilirubinemia. Which supplies should the nurse gather in preparation for this infants treatment plan?
Eye shield patches and an artificial light source for phototherapy.
A client at 40 weeks' gestation receives an anticholinergic, atropine 0.4 mg IM, as an adjunct to inhalation anesthesia for a scheduled Cesarean delivery. Which finding should the nurse identify as a therapeutic response to the injection?
Increase pulse and reduced oral secretions.
A client who is 12 weeks pregnant has type 1 diabetes mellitus. Which instruction should the nurse provide related to insulin dosages?
Increases from 18 weeks to approximately 36 weeks of gestation.
A breastfeeding woman who delivered an infant 2 weeks ago develops mastitis in her left breast. A cephalosporin antibiotic is prescribed after consultation with the infants pediatrician. Which instruction regarding breastfeeding should the nurse provide?
Initiate breastfeeding on the unaffected breast first.
A term multigravida, who is receiving oxytocin for labor augmentation, is requesting pain medication. Review of the clients record indicates that she was medicated 30 minutes ago with butorphanol tartrate 2 mg and promethazine 25 mg IV push. Vaginal examination reveals that the clients cervical dilation is 3 cm, 70 % effaced, and at a 0 station. Which action should the nurse implement?
Instruct the client to use deep breathing during a contraction.
A nulliparous woman who is 2 months postpartum reports not feeling like herself, not wanting to take care for her children and desiring to sleep off the time. How should the nurse respond?
Join a local parent support group.
A client at 32 weeks gestation presents with extreme abdominal tenderness and a small amount of vaginal bleeding. Her blood pressure is 95/65 mmHg, respiratory rate is 24 breaths/ minute, and her heart rate is 116 beats/ minute. She is dizzy with cold clammy skin. Which prescription has the highest priority?
Lactated Ringer's at 200 ml/hr using an 18-gauge needle.
Following an amniocentesis, the client verbalizes several complaints. What reported finding indicates to the nurse the client is experiencing a complication from the amniocentesis.
Low back pain with pelvic cramping
A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first.
Massage the fundus and give an oxytocic agent.
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal... notifying the health care provider of the clients' condition, what information is most.... a. total amount of oxytocin infused b. maternal blood pressure c. apical pulse rate d. time oxytocin infused
Maternal blood pressure
A primipara presents herself to the perinatal unit describing rupture of membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is began and 8 hours later the clients contractions are irregular and mild. Based on these data, the nurse plans to monitor which sign more frequently than for the average laboring client?
Maternal temperature.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
Notify the pediatrician of the cephalohematoma
During a routine perinatal visit, a client at 32 weeks gestation complains that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. What action should the nurse implement?
Obtain a midstream urine specimen for culture
The nurse is providing respiratory practice for an African- American client who is at 24 weeks- gestation. Which prenatal laboratory assessment, prescribed at 20 weeks should the nurse include in infant teaching?
One-hour glucose screen.
A client with a history of substance abuse is attempting to breastfeed at 24- hours postpartum. The nurse observes the infant is irritable with a high- pitched cry, exhibits nasal stuffiness, and is having trouble latching. Which toxicology screening result would indicate these infant behaviors?
Opioids
In assessing a 1-day old male newborn, the nurse observes that the scrotal sac is large swollen, smooth and taut. What assessment technique should the nurse perform to determine if the newborn has hydrocele?
Perform transillumination of the scrotal sac to visualize a red glow of fluid around the testes.
After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next?
Place erythromycin ophthalmic ointment in both eyes
A client in labor states, " I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
Place the client in Trendelenburg
In preparing a gravid client for a triple screen analysis, which action should the nurse take?
Prepare to draw blood for analysis.
Following a vaginal delivery, the nurse observes the neonate under the radiant warmer, previous nasopharyngeal suction and dries the neonates skin to elicit spontaneous respirations. The newborns heart rate is 100 beats/ minute and remains apneic when the nurse taps the soles of the foot. Which action should the nurse implement next?
Provide positive pressure/ premature ventilation
The nurse receives change of shift report for four newborns. The nurse should monitor closely which newborn for an increased risk for developing neonatal sepsis?
Reported prolonged rupture of membranes.
In assessing a client diagnosed with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+, respiratory rate is 12 breaths/ minute, urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mEq/L 4.5 mmo/L. Based on those findings which intervention should the nurse implement.
Stop the magnesium sulfate infusion immediately.
which content should the nurse plan to include in a nutrition class for pregnant adolescents
Take folic acid supplements daily Increase food intake by 300 to 400 calories/ day Take iron and calcium supplements daily
A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant. Which information should the nurse provide?
Techniques to breastfeed
A primigravida client who is 33 weeks gestation presents to the labor and delivery unit with complaints of a headache. The initial assessment findings include: blood pressure 144/ 96 mmHg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
Temperature pulse and respirations.
A postpartum client who is Rh negative refuses to receive Rho (D) immune globulin after delivery of an infant who is Rh positive. Which information should the nurse provide to this client?
The R-positive factor from the fetus threatens her blood cells.
The nurse is reviewing the genetic test report for a for a pregnant client with a history of several spontaneous abortions. The results show the client has a heterozygous z- linked dominant inheritance disorder. How should the nurse explain the results to the client?
There is a 50% chance of passing this gene on to all children.
A client with HSV is receiving zidovudine during labor. Which information should the nurse provide to the client.
This treatment helps prevent the transmission of virus to the fetus.
The nurse is caring for a 35-week gestation infant delivered by cesarean section 2 hours ago. The nurse observes the infants respiratory rate is 72 breaths/ minute with nasal flaring, grunting and retractions. The nurse should recognize these findings indicate which complication?
Transient tachypnea of the newborn.
The nurse is assessing a pregnant client who reports she smokes one pack of cigarette's per day. The client believes she is six-months pregnant, but is unsure of the date of her last menstrual period. Which method of assessment provides the best estimate of gestational age.
Ultrasonography
The nurse is assessing a client at 29 weeks gestation. Which assessment method would provide the most accurate determination of fetal position.
Ultrasound
The nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit levels. What is the best method to obtain this blood sample?
Use a lancet to puncture the outer lateral aspect of the heel
The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?
Uterine atony
Prior to performing a postpartum assessment, the client tells the nurse, " I have pain in my stiches." The nurse notes that there is a mid-line episiotomy. Which action should the nurse take first?
Visualize the perineum and check the episiotomy
A new mother asks the nurse why her infants son has a needle mark on his leg. Which response is best for the nurse to provide this mother?
Your baby was given an injection of vitamin K to prevent bleeding.
