A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.
Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
She was assisted to the bathroom where she voided 150 mL of clear yellow urine.
Lochia rubra is moderate with small clots, no foul odor noted.
The fundus is firm at the umbilicus.
The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.
There is no pain, redness, or swelling in the calves.
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.
The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
The Correct Answer is ["-"]
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While multiple gestation can cause an increase in maternal serum alpha-fetoprotein (MS-AFP) levels, it is not the most likely cause of an elevated MS-AFP level at 17 weeks.
Choice B rationale
Fetal hypoxia, or lack of oxygen to the fetus, is not typically associated with an increase in MSAFP levels.
Choice C rationale
Down syndrome is typically associated with lower, not higher, levels of MS-AFP891011.
Choice D rationale
An elevated level of MS-AFP at 17 weeks is most commonly associated with a neural tube defect. Neural tube defects are birth defects of the brain, spine, or spinal cord that occur during the first month of pregnancy.
Correct Answer is D
Explanation
Choice A rationale
While inspecting the infant’s ears daily can help detect signs of an ear infection early, it does not prevent recurrent otitis media.
Choice B rationale
Positioning the infant prone after feeding does not prevent recurrent otitis media and can actually increase the risk of sudden infant death syndrome.
Choice C rationale
While breastfeeding frequently can provide numerous health benefits for the infant, it does not specifically prevent recurrent otitis media.
Choice D rationale
Avoiding exposure to smoke can help prevent recurrent otitis media in infants. Smoke can irritate the Eustachian tubes, which can lead to fluid buildup and increase the risk of ear infections.
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