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A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce swelling, promote healing, and provide comfort for the client with a fourth-degree laceration. Warm compress can improve circulation and help with pain relief.
Choice B: Providing a cool sitz bath may not be ideal for promoting healing in this case as warmth is more beneficial.
Choice C: Administering methylergonovine is not appropriate for a perineal laceration and can cause unwanted side effects.
Choice D: Applying povidone-iodine after voiding can be irritating to the already sensitive area and may delay healing.
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A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and adding 1 year. In this case, August 10 + 7 days = August 17, subtracting 3 months gives May 17. This calculation estimates the date of delivery. Choice A (May 13) is incorrect as it doesn't account for the full calculation process. Choice C (May 3) is incorrect as it doesn't consider adding 7 days. Choice D (May 20) is incorrect as it doesn't involve subtracting 3 months.
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. Insert a peripher-all access device, Perform daily fetal movement counts, Prepare client for surgery
- B. Ectopic pregnancy, Hyperemesis gravidarum, Gestational diabetes mellitus
- C. Urine ketones, Kleihauer-Betke values,Serum human chorionic gonadotropin (hCG) levels
Correct Answer:
Rationale: Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale: The potential condition the client is most likely experiencing is ectopic pregnancy. The nurse should insert a peripher-all access device to administer medications and fluids, and perform daily fetal movement counts to monitor fetal well-being. The nurse should monitor urine ketones to assess for dehydration and Kleihauer-Betke values to evaluate for internal bleeding, which are common in ectopic pregnancies. Serum human chorionic gonadotropin (hCG) levels should also be monitored to track the progression of the pregnancy and ensure appropriate management.
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 reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). At 20 weeks of gestation, elevated blood glucose levels can indicate gestational diabetes, posing risks for both the mother and fetus. The normal range for fasting blood glucose is 74 to 106 mg/dL, so a value of 180 mg/dL is significantly high. The nurse should report this finding to the provider promptly for further evaluation and management to prevent complications.
A: Hematocrit of 37% is within the normal range for pregnancy.
B: Creatinine level of 0.9 mg/dL falls within the normal range.
C: WBC count of 11,000/mm3 is slightly elevated but can be attributed to the normal physiological changes in pregnancy, such as increased demand on the immune system.
Therefore, choices A, B, and C are not significantly concerning at this stage of gestation compared to the high blood glucose
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to drug withdrawal. Seizure precautions involve ensuring a safe environment, padded crib, monitoring vital signs closely, and having emergency medications and equipment readily available. Monitoring blood glucose every hour (A) is not typically necessary for neonatal abstinence syndrome. Placing the infant on their back with legs extended (B) is a basic positioning technique and not specific to addressing the syndrome. Providing a stimulating environment (D) would be inappropriate and could exacerbate symptoms.