A client is receiving terbutaline (Brethine) IV for preterm labor. Which of the following maternal findings would warrant stopping the infusion?
- A. Cardiac arrhythmias.
- B. Respiratory rate 24 rpm.
- C. Blood pressure 90/60.
- D. Hypocalcemia.
Correct Answer: A
Rationale: Cardiac arrhythmias are a serious side effect of terbutaline and would warrant stopping the infusion to prevent further complications.
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A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act?
- A. A family can choose whether to have health insurance with no consequences.
- B. Primary care physician payments from Medicaid services can equal Medicare.
- C. Adult children up to age 26 are allowed coverage on the parent’s plan.
- D. Private insurance companies can deny coverage for any reason.
Correct Answer: C
Rationale: Adult children up to the age of 26, regardless of student status, are allowed to be covered under their parents’ health insurance plan.
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.
The nurse has received change of shift report on the following four clients. Which of the clients should the nurse assess first?
- A. G1 P0000, 9 weeks’ gestation, hyperemesis gravidarum, vomited twice during the last shift.
- B. G2 P0101, 24 weeks’ gestation, receiving terbutaline po q 2 h for preterm labor, no complaints of cramping during last shift.
- C. G1 P0000, 1 day postpartum, vacuum extraction, for bilateral tubal ligation during this shift.
- D. G2 P0101, 2 days postpartum, spontaneous delivery, had asthma attack during last shift.
Correct Answer: D
Rationale: The client who had an asthma attack during the last shift should be assessed first due to the potential for respiratory complications.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
What assessments or tests would the nurse inform the pregnant patient they can expect to have at each prenatal visit?
- A. hemoglobin
- B. antibody screen
- C. ultrasound
- D. blood pressure
Correct Answer: D
Rationale: The correct answer is D: blood pressure. Monitoring blood pressure is essential during prenatal visits to detect any signs of preeclampsia or high blood pressure, which can be harmful to both the mother and baby. Regular blood pressure checks help ensure the health and well-being of the pregnant patient.
Rationale:
- A: Hemoglobin levels are typically checked to assess for anemia, but this may not be done at every prenatal visit unless there are specific concerns.
- B: Antibody screen is usually done early in pregnancy to check for antibodies that could affect the baby, but it may not be part of routine prenatal visits.
- C: Ultrasound is an important test during pregnancy, but it is not typically done at every prenatal visit unless there are specific concerns or for routine screening.
Summary:
Regular monitoring of blood pressure is crucial during prenatal visits to ensure the well-being of the pregnant patient. Hemoglobin, antibody screen, and ultrasound may not be done at every visit unless there are