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A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because dinoprostone is a medication used to induce labor, which carries risks and requires informed consent. Without informed consent, the client may not fully understand the potential risks and benefits of the medication.
Choice A is incorrect because room temperature is not a specific requirement for administering dinoprostone. Choice B is incorrect as there is no evidence to support placing the client in a semi-Fowler's position after administration. Choice C is incorrect as avoiding urinary elimination is not necessary for this medication.
In summary, obtaining informed consent is the most important action to ensure the client understands the implications of the medication, making choice D the correct answer.
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A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates clot progression or inflammation.
- Tachycardia: Can signify a pulmonary embolism or worsening condition.
- Leukocytosis: Suggests infection or inflammatory response.
- Scant lochia rubra: Not directly related to deep vein thrombosis, more common postpartum.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Initiate anticoagulant therapy, Administer an oxytocic medication, Apply ice packs to the breasts.
- B. Engorgement, Urinary tract infection, Deed vein thrombosis
- C. Temperature, Circumference of lower extremities, Integrity of the nipples
Correct Answer:
Rationale: Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for a client taking digoxin during pregnancy. Digoxin has a narrow therapeutic range, and monitoring the serum level helps ensure the client is taking the medication as prescribed. Option A is not as reliable as self-reporting may not be accurate. Option B, assessing kidney function, is important but not directly related to medication adherence. Option C, determining the apical pulse rate, may indicate the medication's effectiveness but does not confirm adherence. Checking the serum medication level directly assesses the actual drug concentration in the body, providing concrete evidence of adherence.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: Correct Answer: A. "I should empty my bladder before the procedure."
Rationale: Emptying the bladder before amniocentesis helps avoid accidental puncture during the procedure. A full bladder can be in the needle's path, increasing the risk of injury. This statement demonstrates the client's understanding of the importance of bladder emptying.
Incorrect Choices:
B: "I will be lying on my side during the procedure." - Incorrect. The client will typically be lying flat on their back during amniocentesis.
C: "I will be asleep during the procedure." - Incorrect. Amniocentesis is usually done with local anesthesia, so the client will be awake.
D: "I should start fasting 24 hours before the procedure." - Incorrect. Fasting is not required for amniocentesis. It is a simple procedure that does not involve general anesthesia or fasting.