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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Correct Answer is C

Explanation

Choice a reason:

While there is always a risk of introducing infection with an internal examination, this is not the primary concern with placenta previa. Infections are a risk with any invasive procedure, but the precautions taken during a typical internal examination minimize this risk.

Choice b reason:

Initiating preterm labor is a concern with any manipulation of the cervix or uterus during pregnancy. However, at 37 weeks, the pregnancy is considered early-term, and the risk of preterm labor is not the primary concern in the context of placenta previa.

Choice c reason:

The primary reason for avoiding an internal examination in a client with placenta previa is the risk of profound bleeding. With placenta previa, the placenta covers part or all of the cervix. An internal examination could disturb the placenta and lead to significant hemorrhage, which can be life-threatening for both the mother and the fetus.

Choice d reason:

While there is a risk of rupturing the membranes during an internal examination, this is not the primary concern with placenta previa. The main issue is the potential for causing significant bleeding due to the placenta's location over the cervix.

A. Assist the client to turn onto her side. B. Prepare for a cesarean birth. C. Prepare for an immediate vaginal delivery. D. Assist the client to an upright position.

Correct Answer is A

Explanation

Choice A reason: When a client in active labor presents with hypotension, as indicated by a blood pressure reading of 82/52 mm Hg, the priority nursing intervention is to assist the client to turn onto her side. This position helps to alleviate pressure on the inferior vena cava, which can be compressed by the gravid uterus, thereby improving venous return and increasing blood pressure. It also enhances uteroplacental perfusion, providing better oxygenation to the fetus.

Choice B reason: While preparation for a cesarean birth may be necessary if there are signs of fetal distress or if the hypotension does not resolve, it is not the first-line intervention for isolated hypotension without other indications.

Choice C reason: Preparing for an immediate vaginal delivery is not the priority action in response to hypotension. The focus should be on stabilizing the mother's blood pressure to ensure safe delivery, whether vaginal or cesarean.

Choice D reason: Assisting the client to an upright position is not advisable in the case of hypotension, as this can further decrease venous return to the heart and exacerbate the low blood pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not perform an internal examination. Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 40 weeks of gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer is A

Explanation

A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?

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 is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

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?

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 a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

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