A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Administer oxygen at 10 L/min via non-rebreather face mask as needed.

Position the client in lateral side-lying position.

Administer magnesium sulfate IV.

Encourage the client to void every 2 hr.

Administer prophylactic IV antibiotic.

Evaluate the client for uterine tachysystole.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Anticipated:

Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.

Contraindicated:

Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Physicians' Desk Reference (PDR). The PDR is a comprehensive drug reference that provides essential information on medications, including indications, dosages, contraindications, adverse effects, and interactions. It is a reliable resource for nurses to review before administering an unfamiliar medication.
B. State Nurse Practice Act (NPA). The NPA defines the scope of nursing practice and legal responsibilities but does not provide specific drug information. While it guides nurses on legal and ethical aspects of medication administration, it is not a medication reference.
C. Agency for Healthcare Research and Quality (AHRQ). AHRQ focuses on improving healthcare quality and patient safety but does not serve as a primary source for drug-specific information. It provides guidelines and research on best practices rather than detailed medication data.
D. Quality and Safety Education for Nurses (QSEN). QSEN aims to improve nursing education and competency in patient safety but does not offer detailed drug reference materials. It emphasizes principles such as evidence-based practice and quality improvement rather than specific medication details.

A. "Our child has increased his daily caloric intake." B. "Our child is able to complete his homework on time." C. "Our child has a better grasp of reality." D. "Our child has lost some weight since his last appointment."

Correct Answer is B

Explanation

A. "Our child has increased his daily caloric intake." Methylphenidate is a stimulant that commonly suppresses appetite, leading to decreased caloric intake and potential weight loss. An increase in appetite would not indicate medication effectiveness but might suggest the dose is too low or the medication is wearing off.
B. "Our child is able to complete his homework on time." Methylphenidate is used to improve attention, impulse control, and focus in children with ADHD. The ability to complete tasks, such as finishing homework on time, demonstrates improved concentration and executive functioning, which indicates the medication is working effectively.
C. "Our child has a better grasp of reality." ADHD is not primarily associated with a loss of reality testing, as seen in psychotic disorders. While methylphenidate improves focus and impulse control, it does not target symptoms such as delusions or hallucinations.
D. "Our child has lost some weight since his last appointment." Weight loss is a common side effect of methylphenidate due to appetite suppression. While this can be monitored, it does not indicate medication effectiveness in treating ADHD symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is unfamiliar with a medication they are preparing to administer to a client. Prior to administering the medication, the nurse should refer to which of the following resources?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

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A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

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