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A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. This is crucial as peripartum cardiomyopathy can lead to heart failure and hypertension, affecting the client's blood pressure. Monitoring blood pressure twice daily allows for early detection of any changes and timely intervention. Obtaining a prescription for misoprostol (A) is not indicated as it is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Restricting oral fluid intake (C) may worsen the client's condition as adequate hydration is important for cardiac function. Administering an IV bolus of lactated Ringer's (D) could potentially worsen fluid overload and exacerbate heart failure.
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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 digoxin. Digoxin has a narrow therapeutic range, so monitoring the serum level ensures the client is taking the correct dose. Choices A, B, and C do not directly assess medication adherence for digoxin. Asking the client may not reflect the actual medication intake, kidney function assessment is important but not for adherence evaluation, and apical pulse rate may be affected by various factors. Checking the serum level provides objective data on the drug concentration in the body, indicating adherence.
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 is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help the uterus contract and prevent further bleeding. This intervention is crucial in managing postpartum hemorrhage. Administering oxytocin (choice B) can help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice C) is important to prevent uterine atony, but it is not the first priority in this situation. Providing oxygen (choice D) is not directly related to managing postpartum bleeding and should not be the first action.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the most appropriate response because GBS status can change throughout pregnancy, and the risk of transmitting GBS to the newborn is highest during delivery. Testing closer to the due date ensures the most accurate results.
A: Incorrect. GBS may not present with symptoms, so relying on symptoms alone is not a reliable method for testing.
B: Incorrect. Previous negative results do not guarantee current status, as GBS status can change.
C: Incorrect. Lack of indication in earlier prenatal testing does not rule out GBS at the time of delivery.
E, F, G: Not provided, but unnecessary as the correct answer has been identified.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return to the heart, which can increase blood pressure. Placing the client on their side can prevent compression of the vena cava by the uterus, reducing hypotension. Options B and D are not directly related to managing hypotension. Option C is incorrect as massaging the fundus is typically done postpartum to prevent hemorrhage.
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
- A. Oatmeal
- B. Cabbage
- C. Asparagus
- D. Lentils
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have a high fiber content, providing about 15.6 grams of fiber per cooked cup. This high fiber content can help alleviate constipation in the antepartum client. Oatmeal, cabbage, and asparagus have lower fiber content compared to lentils. Oatmeal contains around 4 grams of fiber per cup, cabbage has about 2 grams per cup, and asparagus provides about 3 grams of fiber per cup. Therefore, lentils offer the highest fiber content per cup among the options provided, making them the most suitable choice to address constipation in the antepartum client.