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A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client with hyperemesis gravidarum and a sodium level of 110 mEq/L first. This client is at risk for severe dehydration and electrolyte imbalance, which can lead to serious complications such as metabolic acidosis or organ dysfunction. Prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is not the priority as a client with diabetes mellitus and an HbA1c of 5.8% is within the target range indicating good glycemic control. Choice B, a client with preeclampsia and a creatinine level of 1.1 mg/dL, requires monitoring but is not as urgent as the client with hyperemesis gravidarum. Choice D, a client with placenta previa and a hematocrit of 36%, also needs monitoring but is not as urgently concerning as electrolyte imbalance.
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A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring is a sign of respiratory distress, which is a priority because it indicates potential respiratory compromise. The nurse should assess this newborn first to ensure adequate oxygenation. Subconjunctival hemorrhage (choice B) and overlapping suture lines (choice C) are common findings in newborns and typically do not require immediate attention. Rust-stained urine (choice D) is not a concerning finding in a newborn and can be addressed later.
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
- A. Fasting blood glucose 75 mg/dL
- B. Blood pressure 88/58 mmHg
- C. Urinary output 40 mL/hr
- D. FHR 120/min
Correct Answer: B
Rationale: Correct Answer: B (Blood pressure 88/58 mmHg)
Rationale: Terbutaline is a tocolytic medication used to inhibit preterm labor contractions by relaxing uterine smooth muscle. A low blood pressure of 88/58 mmHg indicates hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased perfusion to the fetus and maternal organs, warranting withholding the medication and notifying the provider for further evaluation and management.
Summary of Incorrect Choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not a concerning finding related to terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not a concerning finding related to terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not a concerning finding related to terbutaline administration.
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1-hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1-hour glucose tolerance test. At 24 weeks, it is important to screen for gestational diabetes. This test helps assess the body's ability to metabolize glucose. The other choices are not typically done at the 24-week appointment. B: Rubella titer is usually done earlier in pregnancy to check immunity. C: Group B strep culture is usually done around 35-37 weeks. D: Blood type and Rh are usually checked at the first prenatal visit.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct Answer: A
Rationale: The correct answer is A, as it encourages the client to make decisions based on their preferences. By stating, "You can bathe and dress your baby if you’d like to," the nurse offers support and control to the client during a difficult time. This empowers the client to engage in meaningful rituals and take control of the situation.
Choice B is incorrect because it imposes guilt on the client by suggesting that not holding the baby will make letting go harder, which may not be the case for everyone. Choice C is incorrect as naming the baby should be a personal decision and not a directive from the nurse. Choice D is incorrect because it assumes the client's readiness for another baby, which may not be the case and can be insensitive.
A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.