A nurse in a prenatal clinic is collecting data from four clients. Which of the following findings is the nurse's priority to report to the provider?

Dysuria

Varicose veins

Gingivitis

Leukorrhea

Answer and Explanation

The Correct Answer is A

A)   Correct - Dysuria (painful urination) could indicate a urinary tract infection (UTI) which, if left untreated, can lead to complications during pregnancy. It requires prompt evaluation and treatment.
B)   Incorrect- Varicose veins and gingivitis are common discomforts during pregnancy, but they are not typically considered urgent issues.
C)   Incorrect- Gingivitis (inflammation of the gums) is common during pregnancy and should be addressed, but it is not as urgent as a potential UTI.
D)   Incorrect- Leukorrhea (white vaginal discharge) is a common occurrence during pregnancy and is usually not a priority concern unless it's accompanied by other symptoms.

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Correct Answer is C

Explanation

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

A. Administer the medication into the deltoid muscle. B. Administer the medication 12 hr after birth. C. Administer the medication with a 25-gauge needle. D. Check the mother's Rh factor prior to administration.

Correct Answer is C

Explanation

A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.

Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.

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A nurse in a prenatal clinic is collecting data from four clients. Which of the following findings is the nurse's priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn whose mother has hepatitis B. Which of the following actions should the nurse plan to take when administering the hepatitis B vaccine?

Correct Answer is C

Explanation

A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

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A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?

A nurse is caring for a client who is postpartum and experiencing excessive vaginal bleeding. Which of the following medications should the nurse plan to administer?

A nurse working on a postpartum unit is collecting data from four clients. Which of the following findings should the nurse report to the provider?

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