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A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?
- A. CO2 combining power
- B. Calcium
- C. Sodium
- D. Chloride
Correct Answer: B
Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.
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At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?
- A. Estimated amount of fluid.
- B. Any odor noted when membranes ruptured.
- C. Color and consistency of fluid.
- D. Time the membranes ruptured.
Correct Answer: C
Rationale: The color and consistency of the amniotic fluid are crucial to assess as they can provide valuable information about the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can lead to complications such as meconium aspiration syndrome in the newborn. Therefore, assessing the color and consistency of the amniotic fluid is the priority in this situation to ensure timely interventions if needed. Estimated amount of fluid (Choice A) may be important but not as critical as assessing for meconium. Any odor noted when membranes ruptured (Choice B) is less relevant compared to assessing for meconium. Knowing the time the membranes ruptured (Choice D) is important but does not take precedence over assessing for fetal distress indicated by meconium presence.
In planning care for a client at 30-weeks gestation experiencing preterm labor, what maternal prescription is most important in preventing this fetus from developing respiratory syndrome?
- A. Betamethasone (Celestone) 12mg deep IM.
- B. Butorphanol 1mg IV push q2h PRN pain.
- C. Ampicillin 1g IV push q8h.
- D. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.
Correct Answer: A
Rationale: The administration of Betamethasone (Celestone) is crucial in cases of preterm labor to promote fetal lung maturation and reduce the risk of respiratory distress syndrome in the newborn. Betamethasone helps enhance the production of surfactant in the fetal lungs, improving their functionality and decreasing the likelihood of respiratory complications upon birth. Butorphanol is an analgesic and not indicated for preventing respiratory syndrome in preterm infants. Ampicillin is an antibiotic used for infection prevention and treatment, not for fetal lung maturation. Terbutaline is a tocolytic agent used to inhibit contractions, but it does not have a direct effect on fetal lung maturity.
When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
- A. At 16 weeks gestation.
- B. At 20 weeks gestation.
- C. At 24 weeks gestation.
- D. At 30 weeks gestation.
Correct Answer: D
Rationale: The best time for the couple to attend childbirth preparation classes is around 30 weeks gestation, which is during the third trimester. Attending classes at this time allows the couple to learn essential information and skills as labor and delivery are approaching, maximizing the benefit of the classes. Option A is too early in the second trimester, and the couple might forget important details by the time labor approaches. Option B is also early in the second trimester, and attending later allows for better preparation. Option C is still in the second trimester, and waiting until the third trimester provides more practical knowledge closer to delivery.
Using N¤gele's rule, what is the estimated date of delivery for a pregnant client who reports that the first day of her last menstrual period was August 2, 2006?
- A. April 25, 2007.
- B. May 9, 2007.
- C. May 29, 2007.
- D. June 2, 2007.
Correct Answer: B
Rationale: N¤gele's rule is used to estimate the date of delivery. It involves adding 7 days to the first day of the last menstrual period (August 2), which gives August 9. Then, subtracting 3 months from August 9, we arrive at May 9 of the following year as the estimated date of delivery. This makes choice B, 'May 9, 2007,' the correct answer. Choices A, C, and D are incorrect as they do not follow the correct calculation based on N¤gele's rule.
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?
- A. Swaddle the infant in a warm blanket.
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Document the findings in the record.
Correct Answer: B
Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.