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A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.
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A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
- A. Varicella
- B. Human papillomavirus
- C. Diphtheria - acellular pertussis
- D. Inactivated influenza
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (A) and Human papillomavirus (B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.