Nokea
Medical History: 24-year-old with type 1 diabetes, gravida 1 para 1, vaginal birth at 37 weeks, newborn 4.1 kg, third-degree laceration. Vital Signs: Temp 37.3°C, BP 128/82 mm Hg, HR 84/min, RR 18/min. Nurses' Notes: Fundus firm, moderate lochia, diaphoretic, clammy, weak, nauseous at 1500. Diagnostic Results: Blood glucose 120 mg/dL at 1300.
The nurse should plan to ___ and ___
- A. Draw blood for culture and sensitivity
- B. Implement seizure precautions
- C. Administer an IV bolus of dextrose 5% in water
- D. Check deep tendon reflexes
- E. Have the client drink 4 oz of regular soda
- F. Check the client's blood glucose level
Correct Answer: F,E
Rationale: Diaphoresis, weakness, and nausea suggest hypoglycemia in a diabetic client. Checking blood glucose confirms the diagnosis, and drinking soda provides fast-acting carbohydrates for a conscious client.
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A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.
Which of the following statements should the nurse include in the teaching?
- A. A group B streptococcus screening will be performed to determine the presence of STIs.
- B. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- C. A multiple marker screening will be performed to identify neural tube defects.
- D. A glucose tolerance test will be performed to predict hyperglycemia in your baby.
Correct Answer: C
Rationale: Multiple marker screening detects neural tube defects like spina bifida, performed between 15-20 weeks.
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.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is planning to administer Rho(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Administer the medication within 72 h after birth
- C. Verify that the newborn is Rh-negative
- D. Verify that the client's Coombs test is positive
Correct Answer: B
Rationale: Rho(D) immune globulin should be given within 72 hours after delivery to prevent Rh isoimmunization in an Rh-negative mother with an Rh-positive newborn.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect to feel pain in my upper right abdomen if I'm having preterm labor.
- B. If I have contractions more often than every 10 minutes, I might be in preterm labor.
- C. I might be experiencing preterm labor if walking stops my contractions.
- D. I can take a daily iron supplement to prevent preterm labor.
Correct Answer: B
Rationale: Frequent contractions (more than every 10 minutes) indicate possible preterm labor, requiring medical evaluation.