A nurse is admitting a client who experienced a vaginal birth 2 hr 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?

Insert an indwelling urinary catheter.

Administer oxygen by nonrebreather mask at 5 L/min.

Methylergonovine 0.2 mg IM now.

Obtain laboratory study of prothrombin and partial thromboplastin time.

Answer and Explanation

The Correct Answer is C

Answer: C. Methylergonovine 0.2 mg IM now.

A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter can be appropriate in a postpartum client, especially if there are concerns about bladder distension, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage. This action does not require clarification.

B. Administer oxygen by nonrebreather mask at 5 L/min.
Although oxygen is commonly delivered at higher rates (10-15 L/min) via a nonrebreather mask, the administration of oxygen at 5 L/min is not harmful. This may be based on the client’s current oxygen needs, but the flow rate might warrant a review.

C. Methylergonovine 0.2 mg IM now.
Methylergonovine is used to control postpartum hemorrhage, but it is contraindicated in clients with hypertension. This client has elevated blood pressure (146/94 mm Hg), and administering methylergonovine could further increase the risk of hypertensive complications. Therefore, this prescription requires clarification due to the risk of hypertensive crisis.

D. Obtain laboratory study of prothrombin and partial thromboplastin time.
Ordering coagulation studies such as prothrombin time (PT) and partial thromboplastin time (PTT) is appropriate, especially in a postpartum client with heavy bleeding, to assess clotting status and rule out any coagulation disorders. This prescription does not require clarification.

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Correct Answer is ["A","C"]

Explanation

A. Indomethacin: Indomethacin, a nonsteroidal anti-inflammatory drug (NSAID), is commonly used to inhibit uterine contractions and delay preterm labor by suppressing prostaglandin synthesis.

C. Magnesium sulfate: Magnesium sulfate is frequently employed to prevent and treat preterm labor due to its tocolytic properties, which help inhibit uterine contractions and delay the onset of labor.

B. Oxytocin: Oxytocin is typically not used for the treatment of preterm labor. It is primarily administered to induce or augment labor in full-term or near-term pregnant individuals.

D. Methylergonovine: Methylergonovine is not commonly used to treat preterm labor. It is primarily indicated for preventing or controlling postpartum hemorrhage by causing uterine contractions.

E. Prostaglandin E2: Prostaglandin E2 is not typically utilized for the management of preterm labor. It is primarily employed for cervical ripening and induction of labor in full-term or near-term pregnant individuals.

A. Report of pain above the umbilicus B. Amniotic fluid in the vaginal vault C. Brownish vaginal discharge D. Cervical dilation

Correct Answer is D

Explanation

A. Report of pain above the umbilicus: Pain above the umbilicus is not a definitive sign of labor. Pain during labor typically originates in the lower abdomen and back, as the uterus contracts to facilitate cervical dilation and effacement.

B. Amniotic fluid in the vaginal vault: While the rupture of membranes (amniotic fluid leaking) can be a sign of labor, its presence alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.

C. Brownish vaginal discharge: Brownish vaginal discharge could indicate the presence of old blood, which might be a sign of bloody show, but it alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.

D. Cervical dilation: Cervical dilation is one of the primary indicators of labor. In a primigravida at 42 weeks of gestation who believes she is in labor, cervical dilation would confirm the onset of labor.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

Correct Answer is D

Explanation

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

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 caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?