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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The priority intervention is to begin FHR (fetal heart rate) monitoring to ensure the fetus is not in distress after the rupture of membranes. This is critical for fetal well-being.
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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open
- C. Both fontanels are the same size.
- D. Both fontanels show molding.
Correct Answer: B
Rationale: The anterior fontanel typically remains open until around 18 months of age, while the posterior fontanel usually closes by 2-3 months. Molding is not an expected finding at this age.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: Administering Rh(0) Immune globulin is a priority for Rh-negative clients after amniocentesis to prevent Rh sensitization, which can occur if fetal blood enters the maternal circulation.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Findings indicating improvement: Fundus at umbilicus, Moderate lochia rubra, Fundus firm to palpation Findings indicating worsening: Blood pressure 80/50 mm Hg, Thready pulse Unrelated finding: Cloudy urine Clinical Implication: The nurse should urgently address the low blood pressure and thready pulse, as they indicate ongoing hemodynamic instability due to postpartum hemorrhage. Immediate interventions such as IV fluids, blood transfusion, and further uterotonic medications may be necessary.
A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the correct dosage, divide the total dose by the dose per tablet. In this case, 2 g = 2000 mg, and each tablet is 250 mg. Therefore, 2000 mg ÷ 250 mg = 8 tablets. This ensures the client receives the correct dosage for effective treatment. Choice B (4 tablets) would result in an underdose, C (2 tablets) would be half the required dose, and D (1 tablet) would be significantly lower than the needed dose, leading to ineffective treatment.