A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?

Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Notify child protective services of the client’s illicit drug use and probable child endangerment.

Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While it’s good that the client has reduced her alcohol intake, consuming alcohol during pregnancy can cause problems for the baby throughout pregnancy, including before a woman knows she is pregnant. Therefore, praising the client for her actions and offering to discuss ways to decrease consumption even more might not be enough.
Choice B rationale
Insisting that the client stop all alcohol use and drawing a blood alcohol level at each prenatal visit could be seen as invasive and might not address the underlying issue of alcohol dependency.
Choice C rationale
Notifying child protective services of the client’s illicit drug use and probable child endangerment is not applicable in this situation as the client has not mentioned any illicit drug use.
Choice D rationale
Referring the client to an outpatient alcohol abuse program for disulfiram therapy could be the most beneficial action. Disulfiram is a drug that is used to support the treatment of chronic alcoholism by producing an acute sensitivity to alcohol.

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Correct Answer is A

Explanation

Choice A rationale
The child’s symptoms of agitation, fever, and back pain, along with a history of asthma and recurrent urinary tract infections (UTIs), suggest that she may be experiencing another UTI1.
UTIs can cause fever and back pain, and the fever can lead to agitation in young children. Administering the prescribed antipyretic would help to reduce the child’s fever and alleviate some of her discomfort.
Choice B rationale
Obstructive uropathy is a condition where the flow of urine is blocked, which can cause pain and kidney damage. While this condition could potentially cause back pain, the child’s other symptoms such as fever and agitation are more indicative of an infection like a UTI1.
Choice C rationale
Albumin is a protein made by the liver that helps keep fluid in the bloodstream so it doesn’t leak into other tissues. It is not a condition but a substance in the body, and therefore would not be the correct answer to the question.
Choice D rationale
V320 is not a known medical condition or term, and therefore would not be the correct answer to the question.

A. Low risk: Routine monitoring. B. Moderate to high risk: Initiate VTE prophylaxis per policy. C. Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. D. High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes.

Correct Answer is B

Explanation

Choice A rationale
Low risk: Routine monitoring. This choice is not the most appropriate. While routine monitoring is important for all patients, those receiving the MMR vaccine are not at an increased risk for Venous Thromboembolism (VTE) or Postpartum Hemorrhage (PPH) based solely on the administration of this vaccine.
Choice B rationale
Moderate to high risk: Initiate VTE prophylaxis per policy. This choice is the most appropriate. The risk of VTE and PPH should be evaluated based on the patient’s overall health status, pregnancy history, and current condition. If the patient is determined to be at moderate to high risk, VTE prophylaxis should be initiated per policy.
Choice C rationale
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Choice D rationale
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella. How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

Correct Answer is B

Explanation

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?