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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.
Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.
Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.
Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.
Correct Answer is C
Explanation
Choice a reason:
Moist skin is not typically associated with SGA newborns. Newborns, in general, may have moist skin shortly after birth due to the amniotic fluid and vernix caseosa, but this is not a distinguishing characteristic of SGA infants.
Choice b reason:
A gray umbilical cord is not a finding specifically associated with SGA. The color of the umbilical cord at birth can vary, and a gray color may indicate that the cord is drying, which is a normal process after clamping and cutting the cord.
Choice c reason:
Wide skull sutures are associated with SGA infants. SGA can be a result of intrauterine growth restriction (IUGR), which can lead to underdevelopment of the skull bones, resulting in wider-than-normal sutures. This is because the skull may not have grown to its expected size due to the growth restriction experienced by the infant.
Choice d reason:
A protruded abdomen is not typically associated with SGA infants. In fact, SGA infants may have a scaphoid or sunken abdomen due to reduced subcutaneous fat and muscle mass. A protruded abdomen in a newborn could be a sign of other conditions such as organomegaly or gastrointestinal issues.
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