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 C

Explanation

Choice a reason:
Slightly below the umbilicus is not the expected location for the fundus at 22 weeks of gestation. Typically, the fundus is located at the level of the umbilicus at 20 weeks and rises about 1 cm above the umbilicus each week thereafter.

Choice b reason:
3 cm above the umbilicus would be more consistent with a gestational age of approximately 23 weeks, as the fundus rises approximately 1 cm per week after reaching the level of the umbilicus at 20 weeks.

Choice C rationale: At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus. The uterus has grown sufficiently by this stage to reach this position, aligning with the expected fundal height measurements. This corresponds with normal pregnancy progression, as fundal height in centimeters is expected to approximate the gestational age in weeks.

Choice D rationale: By 22 weeks of gestation, the fundus has already risen above the umbilicus, so palpating the fundus 3 cm below the umbilicus is inconsistent with normal pregnancy progression. Earlier in pregnancy, such as around 16 to 18 weeks, the fundus might be found below the umbilicus, but this does not apply at 22 weeks.

A. Fundus palpable to the right of midline. B. Less than 2.5 cm of rubra lochia on the perineal pad. C. Client report of increased thirst. D. Client report of frequent uterine contractions.

Correct Answer is A

Explanation

Choice a reason:
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, the bladder can become distended due to decreased sensitivity, which may be caused by trauma during delivery or the effects of anesthesia. A distended bladder can push the uterus to the side and prevent it from contracting properly, leading to increased bleeding. It's important for the nurse to encourage the client to void to relieve bladder distension and allow the uterus to contract effectively.

Choice b reason:
Less than 2.5 cm of rubra lochia on the perineal pad does not necessarily indicate bladder distension. Lochia rubra is the normal discharge of blood, mucus, and tissue from the uterus after childbirth, and its amount can vary widely among individuals. While heavy lochia can be a sign of postpartum hemorrhage, it is not directly related to bladder distension.

Choice c reason:
Increased thirst in a postpartum client is not a direct indicator of bladder distension. Thirst can be influenced by various factors, including dehydration from labor, breastfeeding, or hormonal changes. While it's important for a postpartum client to stay hydrated, increased thirst alone does not suggest a distended bladder.

Choice d reason:
Frequent uterine contractions reported by the client are not a sign of bladder distension. These contractions, known as afterpains, are normal and occur as the uterus contracts to return to its pre-pregnancy size. While uncomfortable, they are a sign of the uterus working to expel blood and tissue and do not indicate bladder issues.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is C

Explanation

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

Explanation

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity from magnesium sulfate therapy and report to the provider?

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?

A nurse in a prenatal clinic is caring for a client. Using Leopold's maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?