Nokea
A nurse is assisting with the admission of a client who has hyperemesis gravidarum.
Which of the following laboratory tests is the priority to complete?
- A. CBC
- B. Serum bilirubin
- C. Urinalysis of ketones
- D. Liver enzymes
Correct Answer: C
Rationale: Urinalysis for ketones is the priority as it indicates ketosis from prolonged vomiting, guiding the need for IV fluids and nutritional support in hyperemesis gravidarum.
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A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Give a bolus of lactated Ringer's
- B. Assist the client to empty her bladder.
- C. Place the client in knee chest position.
- D. Administer methylergonovine IM.
Correct Answer: A
Rationale: A bolus of lactated Ringer's increases intravascular volume, stabilizing blood pressure caused by epidural-induced vasodilation.
A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Lie in a left side-lying position for 30 min after meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Take sips of milk between meals.
Correct Answer: D
Rationale: Sips of milk neutralize stomach acid, relieving heartburn without overfilling the stomach.
A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Round ligament pain
- B. Perineal discomfort and pressure
- C. Tingling in the fingers
- D. Urination urgency and frequency
Correct Answer: D
Rationale: Increased urinary urgency and frequency are common in the first trimester due to hormonal changes and uterine pressure on the bladder.
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 is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Administer NSAIDs every 4 to 6 hr.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Have the client ambulate as often as possible.
Correct Answer: D
Rationale: Early and frequent ambulation promotes circulation, reducing venous stasis and the risk of thrombophlebitis.