A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
Methylergonovine 0.2 mg IM now.
Insert an indwelling urinary catheter.
Obtain laboratory study of prothrombin and partial thromboplastin time.
Administer oxygen by nonrebreather mask at 5 L/min.
The Correct Answer is A
Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.
Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.
Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.
Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.
Correct Answer is B
Explanation
Choice A reason:
Stimulating the infant to cry is an important action as it helps ensure that the baby's lungs are clear of fluid and are functioning properly. However, this is not the first action to take. The initial cry will often occur naturally as part of the transition from intrauterine to extrauterine life.
Choice B reason:
Clearing the respiratory tract is the priority action. Immediately after birth, it is crucial to ensure that the newborn's airway is clear to facilitate breathing. The nurse may suction the mouth and nose to remove any amniotic fluid, mucus, or other obstructions that could impede breathing.
Choice C reason:
Drying the infant off and covering the head is important to prevent heat loss, which newborns are particularly susceptible to due to their large surface area relative to body mass. However, this follows the clearance of the airway, as maintaining an open airway is the most critical initial step in newborn care.
Choice D reason:
Cutting the umbilical cord is a necessary step in the delivery process, but it is not the first action to take when caring for the newborn. The timing of cord clamping can vary, and immediate care focuses on ensuring the newborn's ability to breathe effectively.
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