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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'm having preterm labor.
- B. If 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 possible preterm labor, requiring medical evaluation.
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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 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 time we check on him.
- B. Your baby will wear an electronic bracelet when he is out of your room.
- C. We will match the bracelet on your baby with his footprint record each shift
- D. You should check the identity of individuals who come to remove your baby from the room.
Correct Answer: D
Rationale: Parents should verify the identity of staff to prevent infant abduction, enhancing safety.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 50 degree angle.
- B. I will place the retainer clip at the level of my baby's armpits.
- C. I will place a thick, soft pad behind my baby's back.
- D. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
Correct Answer: B
Rationale: The chest clip should be at armpit level to ensure proper harness positioning for maximum safety.