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A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer's 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump?
- A. 75ml/hr
- B. 100ml/hr
- C. 50ml/hr
- D. 25ml/hr
Correct Answer: A
Rationale: To calculate the infusion rate, divide the total quantity to be infused (500ml) by the total time (1 hour) which equals 500ml/hr. Since the magnesium sulfate is being given at 3g/hr, and 1g of magnesium sulfate is in 5ml of solution, the rate will be 3g/hr x 5ml/g = 15ml/hr. Therefore, the total infusion rate should be 500ml/hr + 15ml/hr = 515ml/hr. Hence, the nurse should program the infusion pump to deliver 75ml/hr (515ml/hr total - 500ml/hr Lactated Ringer's rate).
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The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?
- A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
- B. Suggest placing the iron drops in the orange juice and then feeding the infant.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Give the mother positive feedback about the way she administered the medication.
Correct Answer: D
Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver.
The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences a return to red bleeding after transitioning to pink and white, it may indicate possible complications like hemorrhage or retained placental fragments. Instructing the client to reduce activity level and promptly notify the healthcare provider is crucial for timely evaluation and management of these potentially serious postpartum complications.
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care?
- A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
- B. Determine the child's compliance schedule for subcutaneous NPH insulin (Humulin N).
- C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
- D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).
Correct Answer: A
Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA.
When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometry.
- B. Evaluate cord blood Coombs test results.
- C. Review maternal medical records for blood type and Rh factor.
- D. Prepare the newborn for phototherapy.
Correct Answer: A
Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.
What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct Answer: A
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