The nurse is obtaining the first postpartum meal for a client who has stated that she practices Mormonism (the Church of Jesus Christ of Latter-Day Saints). Which of the following items should the nurse remove from the clients’ food tray?
- A. Caffeinated coffee.
- B. Cheeseburger.
- C. Fried fish.
- D. Pork sausage.
Correct Answer: A
Rationale: Mormons typically avoid caffeinated beverages as part of their religious practices.
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A client is receiving terbutaline (Brethine) IV for preterm labor. Which of the following maternal findings would warrant stopping the infusion?
- A. Cardiac arrhythmias.
- B. Respiratory rate 24 rpm.
- C. Blood pressure 90/60.
- D. Hypocalcemia.
Correct Answer: A
Rationale: Cardiac arrhythmias are a serious side effect of terbutaline and would warrant stopping the infusion to prevent further complications.
The nurse is teaching a patient at 28 weeks of gestation how to perform fetal movement counts. What statement by the patient indicates the patient understands teaching?
- A. I need to count the baby's movements for 1 hour every day.
- B. I should wait to count the baby's movements after work.
- C. If the baby moves less than 10 times in 2 hours, I need to call the midwife.
- D. Once the baby moves 5 times, I can stop counting the movements.
Correct Answer: C
Rationale: The correct answer is C because it accurately reflects the recommended protocol for fetal movement counts. By counting fetal movements over a 2-hour period and contacting the midwife if fewer than 10 movements are felt, the patient demonstrates understanding of the importance of monitoring fetal well-being. This approach aligns with the standard practice of assessing fetal activity as a crucial indicator of fetal health.
Choice A is incorrect because counting for 1 hour may not provide a comprehensive assessment. Choice B is incorrect as it suggests delaying monitoring, which could be dangerous if there are concerns about fetal movement. Choice D is incorrect as it implies stopping the count prematurely, potentially missing crucial information about the baby's activity level.
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.
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 teaching her client about the methods of electronic fetal monitoring during labor. Her client asks which method has the fewest risks to her baby and allows her the most freedom. What is the most appropriate response by the nurse?
- A. Internal and external monitoring have equal risks. You will have to remain in the bed with both of these methods.'
- B. Internal monitoring is a more invasive method, but we only use internal monitoring if we have difficulty obtaining accurate information with external monitoring.'
- C. External monitoring will allow you the most freedom of movement and does not require any invasive procedures for you or your baby.'
- D. External monitoring is not invasive but you have to remain in the bed.'
Correct Answer: C
Rationale: The correct answer is C because external monitoring allows the client the most freedom of movement and does not require any invasive procedures for her or the baby. External monitoring involves placing sensors on the abdomen to monitor the baby's heart rate and the mother's contractions. This method is non-invasive and allows the mother to move around during labor, promoting comfort and mobility.
Choice A is incorrect because internal monitoring is more invasive than external monitoring. Choice B is incorrect because internal monitoring is not used solely based on difficulty obtaining accurate information with external monitoring. Choice D is incorrect because external monitoring does not require the mother to remain in bed; she can move around freely.