A nurse is admitting a client who experienced a vaginal birth 2 hr 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?

Insert an indwelling urinary catheter.

Administer oxygen by nonrebreather mask at 5 L/min.

Methylergonovine 0.2 mg IM now.

Obtain laboratory study of prothrombin and partial thromboplastin time.

Answer and Explanation

The Correct Answer is C

Answer: C. Methylergonovine 0.2 mg IM now.

A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter can be appropriate in a postpartum client, especially if there are concerns about bladder distension, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage. This action does not require clarification.

B. Administer oxygen by nonrebreather mask at 5 L/min.
Although oxygen is commonly delivered at higher rates (10-15 L/min) via a nonrebreather mask, the administration of oxygen at 5 L/min is not harmful. This may be based on the client’s current oxygen needs, but the flow rate might warrant a review.

C. Methylergonovine 0.2 mg IM now.
Methylergonovine is used to control postpartum hemorrhage, but it is contraindicated in clients with hypertension. This client has elevated blood pressure (146/94 mm Hg), and administering methylergonovine could further increase the risk of hypertensive complications. Therefore, this prescription requires clarification due to the risk of hypertensive crisis.

D. Obtain laboratory study of prothrombin and partial thromboplastin time.
Ordering coagulation studies such as prothrombin time (PT) and partial thromboplastin time (PTT) is appropriate, especially in a postpartum client with heavy bleeding, to assess clotting status and rule out any coagulation disorders. This prescription does not require clarification.

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Correct Answer is A

Explanation

A) Peanut butter:
Peanut butter is high in phenylalanine, the amino acid that individuals with phenylketonuria (PKU) are unable to metabolize properly. Therefore, individuals with PKU should avoid consuming foods high in phenylalanine, such as peanut butter.

B) Broccoli
C) Apple juice
D) Potatoes:
These foods are low in phenylalanine and do not need to be eliminated from the client's diet. In fact, they can provide essential nutrients during pregnancy. However, the client should be encouraged to consume foods that are low in phenylalanine to prevent complications associated with PKU.

A. Inform the client the anesthetic effect will last for approximately 6 hr. B. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. C. Administer a 500 mL bolus of 5% dextrose in water prior to induction. D. Have the client stand at the bedside with her arms at her side.

Correct Answer is B

Explanation

A) Inform the client the anesthetic effect will last for approximately 6 hr:
This statement is inaccurate. While the duration of the analgesic effect may vary, epidural analgesia typically provides pain relief for the duration of labor. It is not appropriate to provide a specific time frame like 6 hours as the duration can vary widely depending on the type of medication used and individual response.

B) Obtain a 30-min electronic fetal monitoring (EFM) strip prior to induction:
This is the correct action. It is essential to obtain a baseline fetal heart rate tracing for at least 20-30 minutes prior to initiating epidural analgesia. This allows the healthcare team to assess the fetal status and identify any baseline abnormalities before the initiation of anesthesia.

C) Administer a 500 mL bolus of 5% dextrose in water prior to induction:
This action is not directly related to the preparation for epidural analgesia. Providing a dextrose solution is not a standard practice before epidural placement.

D) Have the client stand at the bedside with her arms at her side:
This action is not appropriate for preparing a client for epidural analgesia. The client should be in a comfortable position, such as sitting or lying on the side, for the procedure.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

Correct Answer is A

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

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 was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct Interpretation of this clinical finding?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)