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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice A) is more indicative of issues like preeclampsia. Temperature elevation (choice C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice D) is more likely related to uterine contractions or gastrointestinal issues.
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A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the dose, divide the total dose by the dose per tablet. In this case, 2 g equals 2000 mg. Therefore, divide 2000 mg by 250 mg (dose per tablet), which equals 8 tablets. Each tablet contains 250 mg, so to reach the total dose of 2000 mg, the nurse needs to administer 8 tablets. Choice B (4 tablets) is incorrect because it would only provide 1000 mg, not the required 2000 mg. Choice C (2 tablets) would provide only 500 mg, not the required dose. Choice D (1 tablet) would provide only 250 mg, which is insufficient.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Hematuria and Proteinuria 2+ are signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which will help to control the bleeding. It is important to address this issue promptly to prevent further complications. Administering oxytocin (choice B) can also help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice C) can relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice D) is not necessary unless the client is showing signs of hypoxia, which is not indicated in the scenario.
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, which can worsen with oxytocin administration due to increased uterine contractions. This can lead to fetal distress and hypoxia. Late decelerations are a sign to stop or decrease the oxytocin infusion and notify the provider. Moderate variability of the FHR (B) is a reassuring sign of fetal well-being. Cessation of uterine dilation (C) may indicate a stalled labor but is not a contraindication for initiating oxytocin. Prolonged active phase of labor (D) may warrant oxytocin augmentation but is not a contraindication.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (A). Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.