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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. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
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A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Verify that the newborn is Rh-negative.
- B. Verify that the client's Coombs test is positive.
- C. Administer the medication into the client's abdomen.
- D. Administer the medication within 72 hours after birth.
Correct Answer: D
Rationale: Administering Rh(D) immune globulin within 72 hours prevents Rh sensitization in Rh-negative mothers, crucial for future pregnancies.
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent.
Which of the following information should the nurse include?
- A. We will scan your baby's identification bracelet each shift.
- B. You should check the identity of individuals who come to remove your baby from the room.
- C. We will match the bracelet on your baby with his footprints each shift.
- D. Your baby will wear an electronic bracelet when he is out of your room.
Correct Answer: B
Rationale: Parents checking identities of individuals removing the baby enhances security, a key safety measure for newborns.
Vital Signs 0830: Temperature: 36.9°C (98.4°F), Heart rate: 89/min, Respiratory rate: 16/min, Blood pressure: 110/60 mm Hg, Oxygen saturation: 97% on room air. 0930: Temperature: 38.2°C (100.8°F), Heart rate: 90/min, Respiratory rate: 20/min, Blood pressure: 120/68 mm Hg, Oxygen saturation: 98% on room air. A nurse is caring for a 27-year-old female client at 32 weeks gestation in the labor and delivery unit admitted for evaluation of a suspected infection during labor.
For each potential provider prescription, click to specify whether the prescription is anticipated or contraindicated for the client: A. Betamethasone 12 mg IM now and repeat in 24 hr, B. Position the client supine, C. Terbutaline 0.25 mg Subcutaneous now, D. Collect a urine sample.
- A. Betamethasone 12 mg IM now and repeat in 24 hr (Anticipated)
- B. Position the client supine (Contraindicated)
- C. Terbutaline 0.25 mg Subcutaneous now (Anticipated)
- D. Collect a urine sample (Anticipated)
Correct Answer: A,C,D
Rationale: Betamethasone aids fetal lung maturity, terbutaline delays preterm labor, and urine sample assesses infection; supine position risks uterine perfusion.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect to feel pain in my upper right abdomen if I am having preterm labor.
- B. I have contractions more often than every 10 minutes. I might be in preterm labor.
- C. I might be experiencing preterm labor if walking stops my contractions.
- D. I can take a daily iron supplement to prevent preterm labor.
Correct Answer: B
Rationale: Frequent contractions (more than every 10 minutes) indicate preterm labor, showing understanding of a key symptom.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever.
- B. Diarrhea.
- C. Sedation.
- D. Diuresis.
Correct Answer: C
Rationale: Sedation is a known adverse effect of nalbuphine hydrochloride, an opioid analgesic that depresses the central nervous system, causing drowsiness.