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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Measure vital signs.

Obtain human chorionic gonadotropin levels.

Collect urine sample for urinalysis.

Recommend bed rest.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

Correct Answer is ["50"]

Explanation

To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.

Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL

Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.

We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

Correct Answer is C

Explanation

Correct Answer is ["50"]

Explanation

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?