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The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.
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A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
- A. Red blood cell count.
- B. Degree of discomfort.
- C. Urinary output.
- D. Temperature.
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.
The physician orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
- A. Diazepam(Valium).
- B. Hydralazine(Apresoline).
- C. Calcium gluconate.
- D. Phenytoin(Dilantin).
Correct Answer: C
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity.
A client asks about the benefits of a hormonal IUD. Which of the following would the nurse include?
- A. It provides protection against STIs.
- B. It can reduce menstrual bleeding over time.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with heavy periods.
Correct Answer: B
Rationale: A hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against STIs, lasts 3-7 years, and is suitable for heavy periods.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
- A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results.
- B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart.
- C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.
- D. Request that the laboratory send the results by email to transfer to the client's electronic record.
Correct Answer: A
Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.