Nokea
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 a client taking digoxin. Digoxin has a narrow therapeutic range, so checking the serum level helps determine if the client is taking the medication as prescribed. If the level is within the therapeutic range, it indicates adherence. Asking the client if they are taking the medication (A) relies on self-reporting, which may not be accurate. Assessing kidney function (B) and determining apical pulse rate (C) are important for monitoring digoxin therapy but do not directly assess medication adherence. Checking the serum medication level provides objective data to confirm adherence.
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A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can result in weakness or paralysis of facial muscles. Polycythemia (choice A) is not typically associated with forceps-assisted births. Hypoglycemia (choice B) may occur in newborns for various reasons, but it is not directly related to the birth method. Bronchopulmonary dysplasia (choice C) is a lung condition usually seen in premature infants, not specifically linked to forceps deliveries. In summary, facial palsy is the most likely complication of forceps-assisted births due to the pressure exerted on the baby's face during the delivery process.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) falls within the normal range for a newborn and does not require immediate reporting.
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 response is appropriate because GBS status can change during pregnancy, and testing closer to the delivery date provides the most up-to-date information. Testing earlier in pregnancy may not accurately reflect the GBS status at the time of delivery.
Choice A is incorrect because the presence of symptoms is not a reliable indicator of GBS status. Choice B is incorrect as past negative GBS results do not guarantee the current status. Choice C is incorrect because GBS screening is typically done later in pregnancy regardless of earlier test results.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment. Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
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: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy can be a sign of ectopic pregnancy, miscarriage, or other complications requiring immediate attention. The nurse should see this client first to assess the situation and provide appropriate interventions.
Choice B is incorrect because tingling and numbness in the right hand is not typically an urgent issue in pregnancy. Choice C is incorrect as constipation, while uncomfortable, is not an immediate concern that requires urgent attention. Choice D is incorrect as bloody noses can be common in pregnancy due to increased blood volume and nasal congestion, but it does not require immediate attention unless severe or persistent.