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The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.
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A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia.
Which of the following medications should the nurse plan to administer?
- A. Acyclovir.
- B. Metronidazole.
- C. Tetracycline.
- D. Amoxicillin.
Correct Answer: D
Rationale: Amoxicillin is a safe, effective antibiotic for treating chlamydia in pregnancy, avoiding fetal harm from alternatives like tetracycline.
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 4 to 6 hours.
Correct Answer: A
Rationale: Encouraging ambulation stimulates circulation, preventing blood clots and reducing thrombophlebitis risk post-cesarean.
History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.
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.
A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Take a break and walk at least once every hour.
- B. Wear the shoulder harness snug across your shoulder.
- C. Position the lap belt across your hips.
- D. Move your car seat forward, close to the steering wheel.
Correct Answer: A
Rationale: Taking breaks and walking hourly during travel improves circulation, reducing the risk of blood clots, a key concern during pregnancy.