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.

Answer and Explanation

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

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Correct Answer is A

Explanation

Choice a reason:
Hydration is crucial during pregnancy, especially for those with preeclampsia. Adequate water intake helps maintain blood volume and reduce blood viscosity, which can help manage blood pressure levels. Drinking 48 to 64 ounces of water daily is recommended to support the increased blood volume needed during pregnancy and to help prevent dehydration, which can exacerbate preeclampsia symptoms.

Choice b reason:
While reducing salt intake can be beneficial for managing blood pressure, it is not necessary to completely avoid salting foods during cooking. Instead, moderation is key. Excessive salt can lead to water retention, which can worsen preeclampsia, but some salt is needed for electrolyte balance and proper body function.

Choice c reason:
Protein is an essential nutrient for fetal growth and the repair and maintenance of maternal tissues. A daily intake of 40 to 50 grams of protein is generally recommended during pregnancy. However, for those with preeclampsia, protein needs may be higher due to potential protein loss in the urine. It's important to monitor protein intake and adjust as needed under medical guidance.

Choice d reason:
Limiting the intake of whole grains, raw fruits, and vegetables is not recommended. These foods provide essential nutrients, fiber, and antioxidants that are beneficial for both maternal and fetal health. They should be included as part of a balanced diet unless there are specific dietary restrictions advised by a healthcare provider.

A. History of migraines B. History of gestational hypertension C. Twin gestations D. Nulliparous E. Oligohydramnios

Correct Answer is ["A","C","D"]

Explanation

Choice a) Reason: History of migraines
Women with a history of migraines may experience an improvement or worsening of their migraine symptoms during pregnancy. Hyperemesis gravidarum, a condition characterized by severe nausea and vomiting, can be associated with migraines due to hormonal changes, stress, or dehydration that pregnancy may exacerbate.

Choice b) Reason: History of gestational hypertension
Gestational hypertension typically develops after 20 weeks of gestation, so it would not be expected in a client at 8 weeks of gestation. Additionally, there is no direct correlation between gestational hypertension and hyperemesis gravidarum.

Choice c) Reason: Twin gestations
Twin or multiple gestations can increase the likelihood of hyperemesis gravidarum due to higher levels of hCG (human chorionic gonadotropin) and other pregnancy-related hormones. These elevated hormone levels are associated with more severe nausea and vomiting.

Choice d) Reason: Nulliparous
Nulliparity (having never given birth) is not directly associated with an increased risk of hyperemesis gravidarum. However, first-time pregnancies can be unpredictable, and the condition can occur regardless of parity.

Choice e) Reason: Oligohydramnios
Oligohydramnios refers to a decreased amount of amniotic fluid and is not typically associated with hyperemesis gravidarum. It is more commonly related to conditions affecting the placenta or fetal kidneys.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

Correct Answer is A

Explanation

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for an adolescent client who is gravida 1, para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the level of the umbilicus. Which of the following actions should the nurse take?

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is caring for a client who is at 28 weeks of gestation and has:

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?