A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?

Methylergonovine 0.2 mg IM now.

Insert an indwelling urinary catheter.

Obtain laboratory study of prothrombin and partial thromboplastin time.

Administer oxygen by nonrebreather mask at 5 L/min.

Answer and Explanation

The Correct Answer is A

Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.

Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.

Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.

Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice a reason:
Limiting alcohol consumption is important during pregnancy to prevent fetal alcohol syndrome and other developmental issues, but it is not specifically related to the prevention of neural tube defects. Alcohol can interfere with the body's ability to absorb certain nutrients, but folic acid intake is the key factor in preventing neural tube defects.

Choice b reason:
Avoiding foods containing aspartame is often recommended for overall health, but there is no direct link between aspartame and neural tube defects. Aspartame is an artificial sweetener found in many diet foods and beverages, and while some people choose to avoid it for various health reasons, it is not specifically associated with neural tube defects.

Choice c reason:
Increasing the intake of iron-rich foods is crucial for preventing anemia during pregnancy and ensuring the baby has enough iron stores. However, iron does not play a direct role in the prevention of neural tube defects. Neural tube defects are related to folic acid, not iron.

Choice d reason:
Consuming foods fortified with folic acid is the most critical factor in preventing neural tube defects. Folic acid is a B vitamin that is essential for the proper development of the neural tube, which becomes the baby's brain and spinal cord. Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects.

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Turn the client onto her left side. C. Encourage the client to walk around without the monitoring unit for 10 minutes, then resume monitoring. D. Offer the client a snack of orange juice and crackers.

Correct Answer is D

Explanation

Choice A reason:
Reporting the situation to the provider and preparing for induction of labor may be premature without first attempting to stimulate fetal movement. Nonstress tests can have periods of no observed movement without indicating immediate distress or the need for labor induction.

Choice B reason:
Turning the client onto her left side can improve uteroplacental blood flow, which might indirectly stimulate fetal movement. However, this action alone may not be sufficient to prompt fetal activity during a nonstress test.

Choice C reason:
Encouraging the client to walk around could potentially stimulate fetal movement, but it is not the standard initial response during a nonstress test. Walking without monitoring may also miss capturing any potential movements that occur during that time.

Choice D reason:
Offering the client a snack of orange juice and crackers is a common and non-invasive method to encourage fetal movement. The natural sugars in the orange juice can increase the baby's blood glucose levels, potentially leading to increased activity that can be observed on the nonstress test.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 minutes. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

A nurse is caring for a newborn delivered by vaginal birth with vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who is postpartum and has received methylergonovine. Which of the following findings indicates that the medication was effective?

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

"How will I know if my baby is getting enough breast milk?"