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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
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A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from the cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (Choice A). This is crucial as an unresponsive client may have compromised breathing which can lead to serious consequences such as hypoxia or respiratory arrest. Assessing respiratory function will help the nurse identify any immediate life-threatening issues and initiate appropriate interventions. Increasing IV fluid rate (Choice B) may be important later but is not the priority in this situation. Accessing emergency medications (Choice C) and collecting a maternal blood sample (Choice D) can also be important but do not address the immediate need to ensure adequate oxygenation. By prioritizing respiratory function assessment, the nurse can quickly address the most critical aspect of the client's care.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A. Abdominal cramping in early pregnancy could be a sign of an ectopic pregnancy or miscarriage, both of which are urgent and potentially life-threatening conditions. The nurse should prioritize assessing this client to rule out any serious complications.
Choice B is not as urgent as choice A because tingling and numbness in the hand are likely due to musculoskeletal or nerve compression issues, which are not immediately life-threatening.
Choice C, constipation, is a common issue in pregnancy and is not typically considered an urgent concern unless accompanied by severe symptoms like abdominal pain or bleeding.
Choice D, frequent bloody noses, is not typically an urgent concern in early pregnancy unless it is accompanied by other severe symptoms like dizziness or excessive bleeding.
In summary, the nurse should prioritize assessing the client experiencing abdominal cramping at 11 weeks of gestation due to the potential seriousness of this symptom in early pregnancy.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to track fetal movement and heart rate patterns. By pressing the button each time fetal movement is felt, the nurse can correlate these movements with any changes in the fetal heart rate, providing valuable information about fetal well-being. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can reduce blood flow to the fetus and is not recommended. Instructing the client to massage the abdomen (C) may lead to inaccurate test results by artificially stimulating fetal movements.