Nokea
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL
- B. 1.0 mL
- C. 2.0 mL
- D. 4.0 mL
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).
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The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
- A. Monitor maternal temperature.
- B. Inspect characteristics of the fluid.
- C. Perform a sterile vaginal examination.
- D. Assess the fetal heart rate pattern.
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
After gathering further information about the edema, the nurse advises the client to limit the intake of which substance?
- A. Sodium
- B. Potassium
- C. Vitamin C
- D. Magnesium
Correct Answer: A
Rationale: Limiting sodium intake helps reduce fluid retention, which contributes to edema in pregnancy.
Which explanation by the nurse correctly describes the occurrence of identical twins?
- A. Two separate ova are fertilized by identical sperm.
- B. The mother releases two identical ova.
- C. One fertilized ovum divides into two identical halves.
- D. Two identical ova are fertilized by two identical sperm.
Correct Answer: C
Rationale: Identical twins result from one fertilized ovum splitting into two identical embryos, sharing the same genetic material.
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
The nurse advises a client with a history of miscarriage to monitor which symptom?
- A. Mild fatigue
- B. Vaginal spotting
- C. Increased appetite
- D. Normal fetal movement
Correct Answer: B
Rationale: Vaginal spotting may indicate a threatened miscarriage, requiring close monitoring and medical evaluation.