Nokea
Nurses' Notes: Client at 38 weeks, reports fluid leaking, suspects ruptured membranes. Mild contractions 20 min apart (0630), 15 min apart (0830). Cervix 2 cm dilated, 20% effaced. FHR 132/min with moderate variability. Vital Signs: Temp 37.1°C, HR 93-95/min, RR 13-15/min, BP 130/76-135/78 mm Hg, O2 sat 99-100%.
After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
- A. Perform a Nitrazine test: Anticipated
- B. Check client's temperature every hour: Nonessential
- C. Check FHR every 30 min: Anticipated
- D. Ensure the client maintains a supine position while in bed: Contraindicated
- E. Prepare the client for catheterization: Nonessential
- F. Encourage frequent ambulation: Anticipated
Correct Answer: A,C,F
Rationale: Nitrazine test confirms ruptured membranes, FHR monitoring every 30 min ensures fetal well-being, and ambulation supports labor progression. Hourly temperature checks and catheterization are not necessary, and supine position risks hypotensive syndrome.
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A nurse is reinforcing teaching with a client who is at 24 weeks of gestation and has opioid use disorder.
Which of the following statements should the nurse make?
- A. You will be prescribed diazepam.
- B. You will be prescribed naloxone.
- C. You will be prescribed aripiprazole.
- D. You will be prescribed methadone.
Correct Answer: D
Rationale: Methadone is the standard treatment for opioid use disorder in pregnancy because it stabilizes opioid levels, preventing withdrawal symptoms and reducing cravings, minimizing risks of fetal distress, miscarriage, and preterm labor.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Limit the client's daily fluid intake
- B. Encourage the client to wear a bra that is loose fitting
- C. Encourage the client to continue to breastfeed.
- D. Prepare the client for an abdominal sonogram
Correct Answer: C
Rationale: Continued breastfeeding prevents milk stasis and reduces the risk of abscess formation in mastitis.
A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test.
Which of the following statements should the nurse make?
- A. You will not be able to eat or drink anything for 8 hours prior to the test.
- B. You will receive medication through an IV line to stimulate contractions.
- C. You will press the provided button when you feel the baby moving during the test.
- D. You will be required to lie flat on your back for the duration of the test.
Correct Answer: C
Rationale: During a nonstress test, the client presses a button when they feel fetal movement to monitor fetal heart rate response, assessing fetal well-being. No fasting, IV medication, or lying flat is required.
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.