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A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
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The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.
A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
History and Physical:
Nurses' Notes:
Vital Signs:
Laboratory Results:
The client is a 28-year-old primiparous female who was induced at 41 weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock.
A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."
The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.
- A. Hemoglobin 10.4 g/dL (6.45 mmol/L)
- B. Platelets 150,000/mm³ (150 x 10â¹/L)
- C. New-onset headache
- D. Vomiting small amount of yellow fluid
- E. Right upper quadrant pain
- F. Seeing flashing lights
- G. Elevated blood pressure
Correct Answer: C,D,E,F,G
Rationale: Headache, vomiting, right upper quadrant pain, flashing lights, and elevated blood pressure suggest postpartum preeclampsia or HELLP syndrome, requiring urgent evaluation.
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation.
- A. She may be experiencing postpartum preeclampsia.
- B. She may have an infection that needs further evaluation.
- C. Her symptoms could indicate anemia due to blood loss.
- D. She may be experiencing normal postpartum fatigue.
Correct Answer: A
Rationale: Symptoms like headache, visual disturbances, and nausea suggest postpartum preeclampsia, unlike infection, anemia, or normal fatigue, which don't typically include these signs.
A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer's 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)
Correct Answer: 36
Rationale: Calculated as: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min; 0.6 mL/min × 60 min/hour = 36 mL/hour.