A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Request a prescription for PRN aspirin from the provider.

Massage the injection site thoroughly following administration.

Instruct the client that they cannot breastfeed while receiving heparin.

Administer the injection in the client's abdomen.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.

Choice B reason:

Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.

Choice C reason:

Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.

Choice D reason:

Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should plan to administer Ampicillin to the client with a group B streptococcus (GBS) B-hemolytic infection. Ampicillin is the first-line antibiotic treatment for intrapartum prophylaxis in GBS-positive pregnant women. It helps prevent the transmission of the bacteria from the mother to the newborn, reducing the risk of early-onset GBS infection in the infant.

Choice B rationale:

Azithromycin is not the appropriate choice for treating GBS B-hemolytic infection during labor. While Azithromycin is effective against certain bacteria, it is not the recommended antibiotic for GBS prophylaxis in labor. Ampicillin or Penicillin is the preferred medication in this scenario.

Choice C rationale:

Ceftriaxone is not the appropriate medication for treating GBS B-hemolytic infection during labor. Ceftriaxone belongs to the cephalosporin class of antibiotics and is not the first-line treatment for GBS prophylaxis. Ampicillin or Penicillin is the preferred choice.

Choice D rationale:

Acyclovir is an antiviral medication and is not indicated for the treatment of GBS B-hemolytic infection. GBS is a bacterial infection, and antiviral medications like Acyclovir do not have an effect on bacteria.

A. Assist the client to a sitz bath. B. Assess the client's uterine tone. C. Encourage the client to breastfeed. D. Apply an ice pack to the client's perineum.

Correct Answer is B

Explanation

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

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A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B- hemolytic infection. Which of the following medications should the nurse plan to administer?

Correct Answer is A

Explanation

A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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