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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.
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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 discharge teaching about home safety with a client who is postpartum.
In which of the following positions should the nurse instruct the client to place their newborn in the crib?
- A. Right lateral
- B. Supine
- C. Prone
- D. Left lateral
Correct Answer: B
Rationale: The supine position reduces the risk of sudden infant death syndrome (SIDS) by keeping the airway open.
Nurses' Notes: Breasts soft, nipples intact, uterus firm at 0700, soft with lateral deviation at 1100, large lochia rubra at 1100, episiotomy site with mild edema/ecchymosis, pain 2-3/10, able to void, DTR 1+, 2+ peripheral edema. Vital Signs: Temp 36.2-37.2°C, HR 80-85/min, RR 16-18/min, BP 136/82-86 mm Hg, O2 sat 99-100%.
Select the findings that require immediate follow-up.
- A. Peripheral edema 2+ bilateral lower extremities
- B. Pain rating of 3 on a scale of 0 to 10
- C. Large amount of lochia rubra
- D. Deep tendon reflexes 1+
- E. Blood pressure 136/86 mm Hg
- F. Uterine tone soft
Correct Answer: C,F
Rationale: Large lochia rubra, soft uterus, and lateral deviation suggest postpartum hemorrhage risk, requiring immediate intervention like fundal massage and bladder assessment.
Nurses' Notes: Client at 38 weeks, reports fluid leaking, suspects ruptured membranes. Mild contractions 20 min apart (0630), 15 min apart (0830). Cervix 2 cm dilated, 20% effaced. FHR 132/min with moderate variability. Vital Signs: Temp 37.1°C, HR 93-95/min, RR 13-15/min, BP 130/76-135/78 mm Hg, O2 sat 99-100%.
After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
- A. Perform a Nitrazine test: Anticipated
- B. Check client's temperature every hour: Nonessential
- C. Check FHR every 30 min: Anticipated
- D. Ensure the client maintains a supine position while in bed: Contraindicated
- E. Prepare the client for catheterization: Nonessential
- F. Encourage frequent ambulation: Anticipated
Correct Answer: A,C,F
Rationale: Nitrazine test confirms ruptured membranes, FHR monitoring every 30 min ensures fetal well-being, and ambulation supports labor progression. Hourly temperature checks and catheterization are not necessary, and supine position risks hypotensive syndrome.
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.