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 C
Explanation
Choice A reason:
A blood glucose level of 96 mg/dL is within the normal range for a fasting blood sugar level in pregnancy, which is typically between 70 to 95 mg/dL. It is crucial to monitor blood glucose levels during pregnancy due to the risk of gestational diabetes, which can have adverse effects on both the mother and the fetus.
Choice B reason:
The production of estrogen is indeed enhanced during pregnancy. Estrogen plays a vital role in maintaining the pregnancy, promoting fetal development, and preparing the body for childbirth. Elevated levels of estrogen are expected and contribute to many of the physiological changes experienced during pregnancy.
Choice C reason:
A heart rate of 120 bpm (beats per minute) can be considered slightly elevated during pregnancy. The normal resting heart rate for a pregnant woman is usually between 60 to 100 bpm. However, during pregnancy, the heart rate can increase to accommodate the increased blood volume and the needs of the growing fetus. Given the information provided, the most likely scenario that the nurse should address is the heart rate of 120 bpm, as it is slightly above the normal range and may need monitoring or intervention.
Choice D reason:
Weakened respiratory contractions are not typically expected during pregnancy. Pregnant women may experience shortness of breath due to the growing uterus pushing against the diaphragm, but the respiratory contractions themselves should not be weakened. If this occurs, it may warrant further investigation.
Correct Answer is A
Explanation
Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.
Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.
Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.
Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.
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