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A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication?
- A. Heart disease.
- B. Cervical dilation of 2 cm.
- C. Gestational age of 34 weeks.
- D. Allergy to penicillin.
Correct Answer: A
Rationale: Terbutaline is contraindicated in heart disease because it can cause tachycardia and arrhythmias, worsening cardiac conditions. Cardiovascular side effects result from its beta-adrenergic agonist action.
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A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.
For each body system below, specify the potential manifestations that the client may experience. Match each body system with the potential manifestation.
- A. Nausea
- B. Pain
- C. Headache
- D. Body aches
Correct Answer: D
Rationale: General: Body aches (D) - reflects systemic discomfort. Head, ears, eyes, nose, and throat: Headache (C) - common neurological symptom. Gastrointestinal: Nausea (A) - due to digestive disturbances. Breast: Pain (B) - related to tissue sensitivity or engorgement.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rh(D) immune globulin.
- B. A client who gave birth 3 days ago and reports breast fullness.
- C. A client who gave birth 12 hours ago and reports an increase in urinary output.
- D. A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Correct Answer: D
Rationale: Saturating a perineal pad every hour 8 hours postpartum indicates heavy vaginal bleeding, potentially signifying postpartum hemorrhage, a life-threatening condition requiring immediate evaluation and intervention.
A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain. Which of the following findings is most consistent with abruptio placenta?
- A. Low uterine tone with mild vaginal bleeding.
- B. Rigid uterine tone with dark vaginal bleeding.
- C. Soft uterine tone with painless vaginal bleeding.
- D. Low uterine tone with absence of vaginal bleeding.
Correct Answer: B
Rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion.
A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication?
- A. Are you taking over-the-counter medications?
- B. Do you have a history of gastric problems?
- C. What kind of contraception will you be using?
- D. Are you being treated for high blood pressure?
Correct Answer: A
Rationale: Ibuprofen can interact with various over-the-counter medications, including anticoagulants and corticosteroids, which may increase risks of side effects like gastrointestinal bleeding or reduced efficacy, necessitating careful assessment of concurrent drug use.