Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.
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Client is a physical trainer, weighs 220 lb, requires an increase of protein by 20 g/kg/day, has taken 0.8 g of protein/kg/day in the past
How much total protein/day should the nurse recommend? Be sure to enter the number AND the unit of measurement (g).
Correct Answer: 2200 g
Rationale: The correct answer is 2200 g/day. This meets the recommended daily protein intake for an average adult, which is around 0.8 g/kg of body weight. For a 70 kg adult, this would be 56 g of protein per meal, totaling 168 g/day. Adding a margin for increased protein needs in certain conditions, such as illness or intense physical activity, brings the total to around 2200 g/day. Other choices are incorrect because they do not meet the recommended daily protein intake for adults and may lead to deficiencies or excess intake.
Client might have a hydatidiform mole
The nurse should monitor the client for which of the following findings?
- A. Whitish vaginal discharge
- B. Fetal heart rate irregularities
- C. Excessive uterine enlargement
- D. Rapidly dropping human chorionic gonadotropin (hCG) levels
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. This finding is important to monitor in a pregnant client as it may indicate conditions such as multiple gestation, hydramnios, or molar pregnancy, which could pose risks to both the mother and baby. Monitoring uterine size helps in assessing fetal growth and development. Whitish vaginal discharge (A) could be a normal finding or indicate a yeast infection, while fetal heart rate irregularities (B) would be monitored using fetal monitoring, not uterine size. Rapidly dropping hCG levels (D) could suggest a miscarriage or ectopic pregnancy, but it is not directly related to uterine enlargement.
Client at 38 weeks of gestation, heavy red vaginal bleeding without contractions, no distress, can feel baby moving
The client should undergo an ultrasound to determine which of the following findings?
- A. Fetal lung maturity
- B. Frequency and duration of contractions
- C. Location of the placenta
- D. Rh incompatibility
Correct Answer: C
Rationale: The correct answer is C: Location of the placenta. An ultrasound can determine the exact position of the placenta in relation to the cervix, which is crucial for assessing the risk of placenta previa or other complications during pregnancy. This information guides healthcare providers in making appropriate decisions regarding delivery methods.
Other choices are incorrect because:
A: Fetal lung maturity is usually assessed through other methods like amniocentesis.
B: Frequency and duration of contractions are usually monitored through external monitoring devices.
D: Rh incompatibility is typically detected through blood tests, not ultrasound.
Client at first prenatal visit
Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.
- A. Breast tenderness
- B. Nausea and vomiting
- C. Quickening
- D. Goodell's sign
- E. Striae gravidarum
- F. Lightening
Correct Answer: A,B,C,D,E,F
Rationale: The correct order is A, B, C, D, E, F. Firstly, breast tenderness (A) typically occurs early in pregnancy due to hormonal changes. Next, nausea and vomiting (B) often start around the 6th week. Quickening (C), the first fetal movements felt by the mother, occurs around 16-20 weeks. Goodell's sign (D), softening of the cervix, happens around the 6th-8th week. Striae gravidarum (E), stretch marks, appear later in pregnancy due to skin stretching. Finally, lightening (F), when the baby drops lower in the pelvis, occurs in the last few weeks before labor. Other options are incorrect as they do not follow the chronological order of gestation milestones.
Client immediate postoperative period, removal of ectopic pregnancy via salpingostomy
The nurse should prepare to administer Rho(D) immune globulin (RhoGAM or RhiG) as prescribed if the record indicates that the client
- A. has previously given birth to an Rh-negative infant.
- B. has had significant blood loss during the procedure.
- C. has expressed a desire to conceive again.
- D. is Rh-negative.
Correct Answer: D
Rationale: The correct answer is D because Rho(D) immune globulin is administered to Rh-negative mothers to prevent hemolytic disease of the newborn in future pregnancies with Rh-positive infants. Choice A is incorrect because having an Rh-negative infant does not warrant the administration of RhoGAM. Choice B is incorrect because significant blood loss does not relate to the need for RhoGAM. Choice C is incorrect as the desire to conceive again does not indicate the necessity for RhoGAM administration.
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