Nokea
The health care practitioner caring for a pregnant client diagnosed with gonorrhea writes the following order: ceftriaxone 250 mg IM × one dose. The medication is available in 1-gram vials. The nurse adds 8 mL of normal saline to the vial. How many mL of the medication should the nurse administer? Calculate to the nearest whole.
- A. 2 mL
- B. 3 mL
- C. 4 mL
- D. 5 mL
Correct Answer: A
Rationale: The nurse should administer 2 mL of the medication. The calculation is based on the concentration of the medication after dilution.
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What is the rationale for a woman in her first trimester of pregnancy to expect to visit her health care provider every 4 weeks?
- A. Problems can be eliminated.
- B. She develops trust in the health care team.
- C. Her questions about labor can be answered.
- D. The conditions of the expectant mother and fetus can be monitored.
Correct Answer: D
Rationale: The correct answer is D because in the first trimester, regular monitoring is crucial to ensure the health and well-being of both the mother and fetus. Visiting every 4 weeks allows the healthcare provider to monitor the progress of the pregnancy, detect any potential issues early on, and provide appropriate interventions if needed. This frequency enables timely adjustments to care plans, such as dietary recommendations or medication changes, to optimize outcomes. Choices A, B, and C are incorrect as they do not directly relate to the primary reason for the regular visits during the first trimester, which is to monitor the conditions of the expectant mother and fetus.
A 39-week-gestation client is admitted to the labor and delivery unit for a scheduled cesarean delivery. The nurse should inform the surgeon regarding which of the following admission laboratory findings?
- A. Potassium 4.9 mEq/L.
- B. Sodium 136 mEq/L.
- C. Platelet count 75,000 cells/mm3.
- D. White blood cell count 15,000 cells/mm3.
Correct Answer: C
Rationale: A platelet count of 75,000 cells/mm3 is low and could increase the risk of bleeding during surgery. The surgeon should be informed to take appropriate precautions.
The nurse is discussing with the patient what laboratory tests are performed at the first prenatal visit. What tests for sexually transmitted infections does the nurse include in the discussion? Select all that apply.
- A. GBS
- B. VDRL
- C. chlamydia culture
- D. hepatitis B
Correct Answer: B
Rationale: The correct answer is B: VDRL. At the first prenatal visit, screening for syphilis is essential to prevent adverse outcomes. VDRL is a standard test for syphilis.
GBS (Group B Streptococcus) testing is typically done later in pregnancy to prevent neonatal infection.
Chlamydia culture is important but not typically done at the first visit; it is usually part of routine prenatal care.
Hepatitis B testing is crucial during pregnancy but not specifically for sexually transmitted infections.
Without doing a vaginal examination, a nurse concludes that a primigravida, who has received no medications during her labor, is in transition. Which of the following signs/symptoms would lead a nurse to that conclusion?
- A. The woman fell asleep during a contraction.
- B. The woman yelled at her partner and vomited.
- C. The woman laughed at something on the television.
- D. The woman began pushing with each contraction.
Correct Answer: B
Rationale: Yelling and vomiting are common signs of the transition phase of labor, characterized by intense contractions and emotional distress.
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.