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A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
- A. Administer oxygen by non-rebreather mask at 5 L/min
- B. Obtain laboratory study of prothrombin and partial thromboplastin time
- C. Methylergonovine 0.2 mg IM now
- D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The correct answer is C: Methylergonovine 0.2 mg IM now. This prescription requires clarification because methylergonovine is a uterotonic medication that can cause severe vasoconstriction, leading to increased blood pressure. Given the client's elevated blood pressure of 146/94 mm Hg, administering methylergonovine could potentially worsen hypertension and lead to adverse effects such as stroke or myocardial infarction. It is crucial to address the high blood pressure before considering the administration of methylergonovine. The other options are not immediately concerning: A) Administering oxygen is appropriate for a client with elevated blood pressure; B) Obtaining laboratory studies is a routine part of postpartum care to assess for coagulation abnormalities; D) Inserting an indwelling urinary catheter is commonly done postpartum to monitor urinary output.
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A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use
- B. Blunt force trauma
- C. Hypertension
- D. Cigarette smoking
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption because it can lead to reduced blood flow to the placenta, increasing the risk of separation. High blood pressure can cause damage to the blood vessels in the placenta, making it more susceptible to detachment. Cocaine use (A) and cigarette smoking (D) can also increase the risk of abruption, but they are not as common as hypertension. Blunt force trauma (B) can directly cause placental abruption but is not as prevalent as hypertension in this context.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
- A. 5
- B. 6
- C. 7
- D. 8
- E. 9
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?
- A. You can push the baby to the room in a wheeled bassinet.
- B. If you show me your photo identification, you can take the infant.
- C. Have the mother ring, and I will take the baby to the room.
- D. You may carry your grandchild to the room.
Correct Answer: C
Rationale: The correct response is C: Have the mother ring, and I will take the baby to the room. This is the appropriate response because it ensures the safety and security of the newborn by confirming the mother's approval before allowing the grandmother to take the baby to the room. This step is crucial to prevent any unauthorized individuals from taking the baby without the mother's consent.
Choice A is incorrect because pushing the baby to the room in a wheeled bassinet may not involve verifying the mother's consent. Choice B is incorrect as asking for photo identification does not confirm the mother's approval. Choice D is incorrect as it assumes the grandmother can carry the baby without checking with the mother first.
In summary, choice C is the correct response as it prioritizes the safety and well-being of the newborn by ensuring the mother's consent is obtained before allowing the grandmother to take the baby to the room.
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
- A. It detects Rh-positive antibodies in the mother’s blood.
- B. It determines the presence of maternal antibodies in the newborn’s blood.
- C. It detects Rh-negative antibodies in the newborn’s blood.
- D. It determines if kernicterus will occur in the newborn.
Correct Answer: A
Rationale: The correct answer is A because the indirect Coombs test detects Rh-positive antibodies in the mother's blood. In Rh incompatibility, Rh-negative mothers can develop antibodies against Rh-positive fetal blood, which can lead to hemolytic disease of the newborn. This test helps identify the presence of these antibodies to prevent harm to the newborn. Choice B is incorrect because the test is done on the mother's blood, not the newborn's. Choice C is incorrect as it refers to the wrong blood type. Choice D is incorrect as kernicterus is related to severe jaundice, not Rh incompatibility.