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A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client with hyperemesis gravidarum and a sodium level of 110 mEq/L first. This client is at risk for severe dehydration and electrolyte imbalance, which can lead to serious complications such as metabolic acidosis or organ dysfunction. Prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is not the priority as a client with diabetes mellitus and an HbA1c of 5.8% is within the target range indicating good glycemic control. Choice B, a client with preeclampsia and a creatinine level of 1.1 mg/dL, requires monitoring but is not as urgent as the client with hyperemesis gravidarum. Choice D, a client with placenta previa and a hematocrit of 36%, also needs monitoring but is not as urgently concerning as electrolyte imbalance.
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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used for infertility, and a common side effect is breast tenderness due to its estrogen-like effects on the body. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate. Tinnitus could be related to ototoxic medications, urinary frequency could be due to diuretics, and chills could be due to infections or allergic reactions, but they are not commonly linked to clomiphene citrate. Therefore, the nurse should focus on educating the client about the potential adverse effect of breast tenderness when taking clomiphene citrate.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. Hemolytic disease in newborns is caused by Rh incompatibility, where the mother is Rh negative and the father is Rh positive. This leads to the mother developing antibodies against the Rh-positive fetal red blood cells, resulting in hemolysis in the fetus. The other choices are incorrect because Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, not when both parents are Rh positive (choice C) or both are Rh negative (choice D). This educational program should emphasize the importance of Rh factor compatibility in preventing hemolytic disease in newborns.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct Answer: B
Rationale: The correct answer is B: A client who has gestational diabetes mellitus. Induction of labor with misoprostol is safe for clients with gestational diabetes mellitus as it does not affect blood glucose levels. Misoprostol is contraindicated in clients with active genital herpes (Choice A) due to risk of viral transmission. It is also contraindicated in clients with a previous uterine incision (Choice C) as it may increase the risk of uterine rupture. Clients with placenta previa (Choice D) should not undergo induction with misoprostol due to the risk of increasing bleeding.
A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider?
- A. Hgb 20 g/dL
- B. Bilirubin 2mg/dL
- C. Platelets 200 .000/mm3
- D. WBC count 32.000/mm3
Correct Answer: D
Rationale: The correct answer is D: WBC count 32,000/mm3. A newborn with a WBC count of 32,000/mm3 indicates a potential infection, as newborns typically have a higher WBC count initially due to stress of birth. It is important to report this finding to the provider for further evaluation and possible treatment. Choices A, B, and C are within normal range for a 24-hour-old newborn, so they do not require immediate reporting. Choice D, Hgb 20 g/dL, is not a typical laboratory finding for a newborn and would require further investigation, but it is not as urgent as a high WBC count indicating infection.