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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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:
Telling a client that a pelvic exam is required for birth control pills is not accurate. Current medical guidelines indicate that a pelvic exam is not necessary to prescribe oral contraceptive medications, hormonal contraceptives can be safely prescribed based on medical history and blood pressure measurement without the need for a pelvic or breast examination.

Choice B reason:
While offering support is important, simply telling the client not to worry does not address her specific concerns or provide her with information about the process and her options.

Choice C reason:
Advising the client to relax does not acknowledge the validity of her feelings or provide her with any concrete information or support to help alleviate her anxiety.

Choice D reason:
Asking the client what part of the exam makes her most nervous is an open-ended question that invites dialogue. It allows the nurse to provide targeted information and reassurance, addressing the client's specific concerns and promoting a sense of control and participation in her own health care decisions.

A. In the third trimester B. Shortly after giving birth C. During her next attempt to get pregnant D. Immediately

Correct Answer is B

Explanation

Choice A reason:
Immunization for rubella in the third trimester is not recommended because live vaccines are contraindicated during pregnancy due to the theoretical risk to the fetus.

Choice B reason:
The recommended time for rubella immunization is shortly after giving birth. This timing is advised because the vaccine contains a live virus, which could potentially harm the fetus if given during pregnancy. By waiting until after the delivery, there is no risk to the newborn, and the mother can develop immunity before any subsequent pregnancies.

Choice C reason:
While it is important for a woman to have immunity to rubella before getting pregnant, the immunization should not be given during the time she is trying to conceive. Women are advised to avoid pregnancy for at least 28 days after receiving the MMR vaccine, which includes the rubella component, due to the live virus in the vaccine.

Choice D reason:
Immunization for rubella should not be given immediately upon finding out that the client does not have immunity during the first trimester. As mentioned, live vaccines are contraindicated during pregnancy, and the immunization should be postponed until after the birth of the baby.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

Correct Answer is B

Explanation

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

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 completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

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)

A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?