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A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side has fewer nerve endings, making it less painful for the client. Additionally, it reduces the risk of injury to the nerves and blood vessels located on the other sides of the finger. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (choice B) may lead to inaccurate results due to improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and potentially affect the glucose level. Therefore, selecting the lateral side of the finger for puncture is the best practice for obtaining a 2-hr postprandial blood glucose sample.
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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.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage. Vacuum-assisted delivery can cause trauma to the birth canal and uterus, also increasing the risk. History of uterine atony indicates a previous inability of the uterus to contract effectively after delivery, predisposing the client to postpartum hemorrhage.
Incorrect answers:
B: Newborn weight is not directly related to the risk of postpartum hemorrhage.
E: History of human papillomavirus does not increase the risk of postpartum hemorrhage.
In summary, choices A, C, and D are directly linked to postpartum hemorrhage risk due to their impact on uterine contraction and trauma during delivery, while choices B and E are not causative factors.
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.
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.
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 relevant findings that may indicate a potential worsening condition.
- Leukorrhea is unrelated to the diagnosis and should not be considered for interpretation.
- Positive clonus is a sign of potential improvement as it suggests a neurological response.
- BUN 40 mg/dL is a critical value that indicates potential renal impairment.
- Platelet count 110,000/mm3 is a concerning finding that suggests a potential worsening condition.