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A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?
- A. Schedule a visit with the healthcare provider today.
- B. Verify the compatibility of the administered Rho(D) immune globulin.
- C. Encourage the client to increase her intake of oral fluids.
- D. Instruct the client to maintain bedrest for 24 hours.
Correct Answer: C
Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.
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A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
- A. Pain level
- B. Blood pressure
- C. Infusion site
- D. Contraction pattern
Correct Answer: D
Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.
A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?
- A. Weak cry without tears.
- B. Bulging fontanel.
- C. Visible peristaltic wave.
- D. Palpable mass in the right upper quadrant.
Correct Answer: A
Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
- A. Weight gain.
- B. Reduction of fever.
- C. Improved caloric intake.
- D. Reduction of edema.
Correct Answer: D
Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant's growth chart
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit a positive scarf sign on the affected side.
- B. Observe for an asymmetrical Moro (startle) reflex.
- C. Watch for swelling of fingers on the affected side.
- D. Note paralysis of the affected extremity and muscles.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.