Nokea
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who has a positive pregnancy test
- B. A client who smokes one pack of cigarettes per day
- C. A client who has a history of gallbladder disease
- D. A client who is nulliparous
Correct Answer: A
Rationale: An IUD is contraindicated in pregnancy due to risks of miscarriage, infection, and preterm labor.
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A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Administer NSAIDs every 4 to 6 hr.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Have the client ambulate as often as possible.
Correct Answer: D
Rationale: Early and frequent ambulation promotes circulation, reducing venous stasis and the risk of thrombophlebitis.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 50 degree angle.
- B. I will place the retainer clip at the level of my baby's armpits.
- C. I will place a thick, soft pad behind my baby's back.
- D. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
Correct Answer: B
Rationale: The chest clip should be at armpit level to ensure proper harness positioning for maximum safety.
Nurses' Notes: Client at 28 weeks, gravida 4, para 3, vaginal bleeding for 2 hr, saturating pads with bright red blood, no abdominal pain. Abdomen soft, nontender, fundal height 27 cm, FHR 170/min with minimal variability. Vital Signs: Temp 36.6°C, HR 120/min, RR 22/min, BP 86/48 mm Hg, O2 sat 96%. Diagnostic Results: Hct 25%, Hgb 9 g/dL, Platelet 110,000/mm3, WBC 12,000/mm3, Blood type B+.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Monitor administration of ampicillin 2g IV bolus, Reinforce with the client to maintain bed rest, Administer methotrexate, Insert a large bore peripheral IV cathete, Assist the client with positioning for a vaginal examination
- B. Ectopic pregnancy, Placenta Previa, Cervical insufficiency, Chorioamnionitis
- C. Cervical dilatation, Vaginal bleeding, Fetal wellbeing, WBC count, Beta human chorionic gonadotropin levels
Correct Answer: A
Rationale: Painless, bright red bleeding at 28 weeks suggests placenta previa. Bed rest minimizes bleeding risk, and IV access prepares for fluid resuscitation. Monitoring bleeding and fetal well-being assesses stability.
Nurses' Notes: Newborn lightly swaddled, jittery, weak cry, mottled extremities, acrocyanosis, rapid respirations. History: Gravida 2 Para 2, vaginal birth at 41 weeks, maternal syphilis treated, intermittent cannabis use. Vital Signs: Temp 36°C, HR 132/min, RR 72/min, Weight 4,366 g. Diagnostic Results: Maternal blood type A+, RPR/VDRL negative, urine drug screen positive for marijuana.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Collect a urine specimen, Monitor the new born after receiving penicillin IM, Reinforce with the parent to feed the newborn, Anticipate a prescription to obtain a capillary blood, Monitor the new born while receiving phototherapy
- B. Hypoglycaemia, Kernicterus, Congenital Syphilis, Neonatal abstinence syndrome
- C. Skin integrity, Bilirubin levels, Respiratory Status, Environmental stimuli, Temperature
Correct Answer: A
Rationale: Jitteriness, weak cry, and large birth weight suggest hypoglycemia. Feeding stabilizes glucose, and capillary blood confirms diagnosis. Monitoring respiratory status and temperature assesses progress.
A nurse is collecting data from a client who is at 28 weeks of gestation.
Which of the following findings is the nurse's priority?
- A. FHR 160/min
- B. Fundal height 24 cm
- C. Blood pressure 136/84 mm Hg
- D. Trace protein on urine reagent strip
Correct Answer: B
Rationale: A fundal height of 24 cm at 28 weeks is lower than expected, suggesting intrauterine growth restriction, requiring further evaluation.