Nokea
The nurse is reviewing the chart of a client who gave birth 4 hours ago. Which factor increases the client's risk for postpartum hemorrhage?
- A. Labor and birth without pain medication
- B. Labor length of 8 hours
- C. Newborn weight of 9 lb 2 oz (4140 g)
- D. Third stage of labor lasting 20 minutes
Correct Answer: C
Rationale: A large newborn (macrosomia, >4000 g) increases the risk of uterine atony, a major cause of postpartum hemorrhage. Labor without pain medication, an 8-hour labor, and a 20-minute third stage are not significant risk factors.
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The nurse is responsible for teaching the client regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium?
- A. Apple
- B. Spinach
- C. Liver
- D. Squash
Correct Answer: B
Rationale: Spinach is a rich source of magnesium, found in green leafy vegetables, nuts, and whole grains. Apple , liver , and squash have lower magnesium content.
A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce the need to report which symptom?
- A. Abdominal discomfort
- B. Insomnia
- C. Morning headache
- D. Muscle aches or weakness
Correct Answer: D
Rationale: Muscle aches or weakness may indicate myopathy or rhabdomyolysis, serious rosuvastatin side effects. Abdominal discomfort, insomnia, and headaches are less specific.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
- A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning
- B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning
- C. Discard urine and container, have client void, add urine to new container, and then restart test
- D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM
Correct Answer: B
Rationale: Discarding a specimen invalidates the 24-hour collection, requiring a restart to ensure accurate results. Adding volume, restarting mid-collection, or relabeling compromise test integrity.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.