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A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Double vision
- B. Pedal edema
- C. Weight gain of 1 kg (2.2lb)
- D. BP of 132/84mm Hg
Correct Answer: A
Rationale: Double vision suggests severe preeclampsia, requiring immediate evaluation to prevent complications like eclampsia.
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Vital Signs: Blood pressure 130/70 mm Hg, Temperature 38.6° C (101.5° F), Respiratory rate 18/min, Heart rate 102/min, Oxygen saturation 98% on room air. History and Physical: Delivered at 37 weeks of gestation, Routine prenatal care, Iron-deficiency anemia, Rubella immune, Shellfish and penicillin allergy. Current Diagnosis: Mastitis. Laboratory Test Results: Blood type O+, Creatinine 0.8 mg/dL, WBC count 9,500/mm3. Medication Administration Record: Ibuprofen 800 mg PO every 6 hr PRN pain, Doxycycline 100 mg PO every 12 hr, Ferrous sulfate 325 mg PO twice daily, Folic acid 0.5 mg PO once daily, Bisacodyl 10 mg PO once daily, Rho(D) immune globulin 300 mcg IM x1. A nurse is preparing to assist with the administration of medications to a client who is 72 hr postpartum following a caesarean birth.
Which of the following medications requires clarification prior to administration? The nurse should clarify the prescription for ___ because ___
- A. Rho(D) immune globulin; of the client's blood type.
- B. Ibuprofen; of the client's WBC count.
- C. Doxycycline; of the client's heart rate.
- D. Bisacodyl; of the client's blood type.
Correct Answer: A
Rationale: Rh (D) immune globulin is given to Rh-negative clients to prevent Rh sensitization. Since the client is O+ (Rh-positive), there is no risk of Rh incompatibility, making this medication unnecessary.
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 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 preparing to administer metronidazole 2 g PO. The amount available is 500 mg tablets.
How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: 4 tablets
Rationale: 2 g = 2000 mg; 2000 mg / 500 mg/tablet = 4 tablets.
A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should feed your baby six times a day.
- B. You should wake your baby at least every 6 hours at night for feedings.
- C. You should recognize that your baby sucking on his hands is a hunger cue.
- D. You should feed your baby for 10 minutes on each breast.
Correct Answer: C
Rationale: Sucking on hands is an early hunger cue, aiding effective feeding by recognizing the baby's needs.