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Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
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Client regarding how to reduce the risk of giving birth to a newborn who has a neural tube defect
Which of the following instructions by the nurse is appropriate?
- A. Increase intake of iron.
- B. Eat foods fortified with folic acid.
- C. Avoid the use of aspirin.
- D. Limit consumption of alcohol.
Correct Answer: B
Rationale: The correct answer is B: Eat foods fortified with folic acid. This instruction is appropriate because folic acid is crucial during pregnancy for preventing birth defects. Iron intake (A) is important too, but not the most appropriate here. Aspirin avoidance (C) is relevant due to its potential risks. Limiting alcohol (D) is important, but not as critical as folic acid. The other choices are not applicable or less crucial in this context.
Client in second trimester
The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
- A. Increased abdominal muscle tone
- B. Decreased mobility of pelvic joints
- C. An increase in lordosis
- D. Posterior neck flexion
Correct Answer: C
Rationale: The correct answer is C: An increase in lordosis. During pregnancy, the center of gravity shifts forward due to the growing uterus, leading to an increase in the curvature of the lumbar spine (lordosis). This change helps to maintain balance and compensate for the added weight of the developing fetus. Increased abdominal muscle tone (choice A) is not an expected change as the abdominal muscles may actually stretch and weaken to accommodate the growing uterus. Decreased mobility of pelvic joints (choice B) is incorrect because during pregnancy, hormonal changes can actually increase the mobility of pelvic joints to prepare for childbirth. Posterior neck flexion (choice D) is unrelated to the physiologic changes in pregnancy.
Client at 28 weeks of gestation, history of one elective abortion at 9 weeks, birth of twins at 36 weeks, spontaneous abortion at 15 weeks
According to the GTPAL system, which of the following describes her present parity?
- A. 4-0-0-2-2
- B. 4-2-0-2-2
- C. 4-0-2-2-2
- D. 4-0-1-2-2
Correct Answer: D
Rationale: According to the GTPAL system, "G" represents the total number of pregnancies. In this case, the correct answer is D (4-0-1-2-2) because it indicates the woman has had 4 pregnancies, 0 term births, 1 preterm birth, 2 living children, and 2 abortions/miscarriages. This is the correct interpretation of her present parity. Choices A, B, and C have incorrect numbers for preterm births, living children, or abortions/miscarriages, making them incorrect.
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.
Client pregnant, taking iron supplements for iron-deficiency anemia, reports black stools, no abdominal pain or cramping
Which of the following responses by the nurse is appropriate?
- A. What else have you been eating?
- B. Go to the emergency room and your provider will meet you there.
- C. This is expected because of the way iron is broken down during digestion.
- D. Come to the office and we will check things out.
Correct Answer: C
Rationale: The correct answer is C because it provides an appropriate explanation for the situation. Iron is known to cause dark stools due to its breakdown in the digestive system. This response shows understanding and reassures the patient. Choice A is relevant but doesn't address the specific issue. Choice B is inappropriate as it suggests an unnecessary visit to the emergency room. Choice D is a general invitation without addressing the concern.