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A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.
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A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
- A. Evaluate fetal heart rate and contraction patterns.
- B. Obtain prescription to repeat hepatic panel.
- C. Monitor for evidence of seizure activity.
- D. Check the urinary output in hourly urinometer.
- E. Inspect the perineum for vaginal bleeding.
Correct Answer: A,B,C,D
Rationale: Monitoring fetal heart rate, repeating hepatic panel, checking for seizures, and assessing urinary output address potential HELLP syndrome and renal function in preeclampsia.
A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
- A. Obtain a blood glucose level.
- B. Feed the infant glucose water (10%).
- C. Administer oxygen.
- D. Decrease environmental stimuli.
Correct Answer: A
Rationale: Obtaining a blood glucose level confirms hypoglycemia as the cause of jitteriness, common in LGA infants of diabetic mothers, guiding treatment.
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.
The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
- A. Offer a pacifier dipped in glucose water.
- B. Give a PRN dose of liquid acetaminophen.
- C. Place petrolatum gauze dressings on the site.
- D. Wrap the infant in warm receiving blankets.
Correct Answer: C
Rationale: Petrolatum gauze prevents wound adherence to diapers, reducing irritation and infection risk, prioritizing post-circumcision care.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.