Nokea
The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?
- A. Assess the amount and color of bleeding.
- B. Place the client in a Trendelenburg position.
- C. Administer Rho(D) immune globulin.
- D. Perform a vaginal examination.
Correct Answer: A
Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.
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Medication that are contraindicated for management of PPH include SATA (Cytotec, Hemabate, Pitocin, Methergine all for PPH)
- A. Terbutaline (for preterm labor)
- B. Magnesium sulfate
- C. Methergine
- D. Pitocin
Correct Answer: A
Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.
An adolescent patient calls the office and asks to speak with the nurse. The patient cannot remember where she can place her contraceptive patch. What area of the body should the nurse tell her to avoid?
- A. breasts
- B. abdomen
- C. buttocks
- D. arm
Correct Answer: A
Rationale: The nurse should advise the adolescent patient to avoid placing the contraceptive patch on her breasts. The contraceptive patch is typically recommended to be placed on areas of the body with minimal hair and movement to ensure proper adherence and absorption of hormones. Placing the patch on the breasts may result in movement and friction, causing it to become dislodged or less effective. It is important to follow the specific instructions provided with the contraceptive patch on where to apply it for optimal effectiveness.
A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread.
- B. A sliced apple and red grapes.
- C. A chocolate chip cookie with a glass of skim milk.
- D. A scrambled egg with cheddar cheese.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder where the body cannot metabolize phenylalanine, an amino acid found in protein-containing foods. Patients with PKU need to follow a strict low-phenylalanine diet to prevent the buildup of phenylalanine in the body. Fruits like apples and grapes are low in protein and contain minimal phenylalanine, making them suitable choices for individuals with PKU. The other options listed contain higher amounts of protein and phenylalanine, such as peanut butter, chocolate chip cookies, milk, scrambled eggs, and cheese, which should be avoided by individuals with PKU.
The nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result folic acid deficiency?
- A. iron deficiency anemia
- B. Poor bone formation
- C. Macrosomia fetus
- D. Neural tube defect
Correct Answer: D
Rationale: Folic acid is essential for the development of the neural tube in the fetus. When a pregnant woman has a deficiency in folic acid, it can lead to neural tube defects in the fetus. Neural tube defects are serious birth defects that affect the brain, spine, or spinal cord of the baby. The most common types of neural tube defects include spina bifida and anencephaly. Therefore, it is crucial for women of childbearing age to ensure an adequate intake of folic acid to prevent such birth defects.
A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in her newborn that would indicate to the nurse that the baby has been affected with fetal alcohol syndrome would be:
- A. Cleft lip
- B. Polydactyly
- C. Umbilical Hernia
- D. Small upturned nose neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am ï‚· Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain ï‚· Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr. ï‚· Mom may breastfeed ad lib ï‚· Draw blood cultures x 3 in A.M. ï‚· Urine C&S in A.M.
Correct Answer: D
Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.