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 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.

A. Initiate IV access. B. Witness the signature for informed consent for surgery. C. Insert an indwelling urinary catheter. D. Prepare the abdominal and perineal areas.

Correct Answer is A

Explanation

Choice A reason:
In the case of a client with painless, bright red vaginal bleeding at 38 weeks of gestation, the priority is to stabilize the client's condition. Initiating IV access is crucial as it allows for rapid administration of fluids or blood products to address potential hypovolemia and to prepare for the possibility of an emergency cesarean section if needed. The client's low blood pressure and elevated heart rate suggest that she may be experiencing hypovolemia, which can quickly lead to hypovolemic shock if not treated promptly.

Choice B reason:
While obtaining informed consent is important before any surgical procedure, it is not the immediate priority. The priority is to stabilize the client, and consent can be obtained concurrently with other stabilizing actions or by another member of the healthcare team.

Choice C reason:
Inserting an indwelling urinary catheter is a supportive measure that can be necessary during labor or before surgery to keep the bladder empty, reducing the risk of bladder injury during a cesarean section and monitoring urine output as an indicator of renal perfusion. However, it is not the first priority in the presence of significant vaginal bleeding.

Choice D reason:
Preparing the abdominal and perineal areas is part of the preoperative procedure for a cesarean section. This action would follow after the client has been stabilized and a decision for surgery has been made.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make?

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 instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

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?

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 experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?