Nokea
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation(DIC)?
- A. Ringer's lactate solution.
- B. Fresh frozen platelets.
- C. 5% dextrose solution.
- D. Warfarin sodium(Coumadin).
Correct Answer: B
Rationale: Fresh frozen platelets are used to manage bleeding in DIC.
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After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
- A. I'll burp him after 15 minutes of feeding him formula.
- B. After he takes one-half ounce of formula, I'll burp him.
- C. I'll burp him while he is in an upright position.
- D. I'll gently pat his back to get him to burp.
Correct Answer: B
Rationale: Burping after one-half ounce is too frequent and may disrupt feeding; burping every 1-2 ounces is more appropriate.
An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with the health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?
- A. Satisfaction with prior methods.
- B. Preference of sexual partner.
- C. Breast- or bottle-feeding plan.
- D. History of clotting disease.
Correct Answer: D
Rationale: A history of clotting disease significantly impacts birth control options, as hormonal methods like combined oral contraceptives may increase the risk of thromboembolism, making non-hormonal or progestin-only methods safer choices.
A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.
A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?
- A. 8 hours.
- B. 24 hours.
- C. 72 hours.
- D. 96 hours.
Correct Answer: C
Rationale: RhoGAM should be administered within 72 hours postpartum to prevent Rh sensitization.
A primiparous client, 48 hours after a vaginal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
- A. Orange juice.
- B. Herbal tea.
- C. Milk.
- D. Grape juice.
Correct Answer: A
Rationale: Vitamin C in orange juice enhances iron absorption, unlike milk, which can inhibit it.