A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?
- A. 45
- B. 15 mL
- C. 4
- D. 13
Correct Answer: D
Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.
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A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?
- A. Refer the mother to the Centers for Disease Control and Prevention.
- B. Report the incident to the school principal.
- C. Culture the bite site when the child returns to school.
- D. Schedule a test for Lyme disease if a rash appears.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?
- A. Gravidity and parity.
- B. Time and amount of last oral intake.
- C. Date of last normal menstrual period.
- D. Frequency and intensity of contractions.
Correct Answer: C
Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus.
A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?
- A. Assess her blood pressure.
- B. Apply an ice pack to the perineum.
- C. Allow the infant to breastfeed.
- D. Massage the fundus vigorously.
Correct Answer: A
Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Inform her that a decreased need for insulin occurs while breastfeeding.
- B. Counsel her to increase her caloric intake.
- C. Advise the client to breastfeed more frequently.
- D. Schedule an appointment for the client with the diabetic nurse educator.
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
- A. Round ligament strain.
- B. Chorioamnionitis.
- C. Abruptio placenta.
- D. Viral infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.