Nokea
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.
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A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Take an over-the-counter antacid
- B. Eat dry, bland foods in the morning
- C. Restrict fluids to 1,000mL/day
- D. Increase intake of fresh fruits
Correct Answer: B
Rationale: Eating dry, bland foods like crackers in the morning stabilizes blood sugar and reduces nausea.
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Polyuria
- B. Hyporeflexia
- C. Agitation
- D. Tachypnea
Correct Answer: B
Rationale: Hyporeflexia is an early sign of magnesium toxicity, indicating excessive neuromuscular blockade, requiring immediate reporting.
A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Stroke upward on the lateral aspect of the sole of the newborn's foot.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Pull the newborn up by the wrist from a supine position
- D. Touch the corner of the newborn's mouth
Correct Answer: A
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, causing dorsiflexion of the big toe and fanning of other toes in newborns.
Nurses' Notes: Breasts soft, nipples intact, uterus firm at 0700, soft with lateral deviation at 1100, large lochia rubra at 1100, episiotomy site with mild edema/ecchymosis, pain 2-3/10, able to void, DTR 1+, 2+ peripheral edema. Vital Signs: Temp 36.2-37.2°C, HR 80-85/min, RR 16-18/min, BP 136/82-86 mm Hg, O2 sat 99-100%.
Select the findings that require immediate follow-up.
- A. Peripheral edema 2+ bilateral lower extremities
- B. Pain rating of 3 on a scale of 0 to 10
- C. Large amount of lochia rubra
- D. Deep tendon reflexes 1+
- E. Blood pressure 136/86 mm Hg
- F. Uterine tone soft
Correct Answer: C,F
Rationale: Large lochia rubra, soft uterus, and lateral deviation suggest postpartum hemorrhage risk, requiring immediate intervention like fundal massage and bladder assessment.