A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

Weight gain 2.3 kg (5 lb)

Frequent nausea

Breast tenderness

Persistent headache

Answer and Explanation

The Correct Answer is D

A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.

B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.

C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.

D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.

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Correct Answer is C

Explanation

Rationale:

A. Urine output 20 mL/hr: This urine output is below the recommended minimum of 30 mL/hr and may indicate magnesium toxicity or worsening renal perfusion. It is not a therapeutic effect and requires prompt evaluation.

B. BP 150/92 mm Hg: This blood pressure is still elevated and does not indicate optimal control of preeclampsia. Magnesium sulfate is given to prevent seizures, not primarily to lower blood pressure, so this is not a measure of therapeutic effect.

C. Absence of eclampsia: Magnesium sulfate is administered in preeclampsia to prevent the onset of eclampsia (seizures). The absence of seizure activity indicates that the medication is having its intended therapeutic effect.

D. FHR 116/min: This fetal heart rate is within the normal baseline range of 110–160/min, but it is not a direct therapeutic effect of magnesium sulfate. It is more a reflection of fetal well-being rather than the drug’s primary purpose.

A. Cleanse the insertion site of the drain using a circular motion toward the center. B. Irrigate the wound with a low-pressure flow of solution. C. Irrigate the wound using a 10-mL syringe. D. Cleanse the wound starting at the bottom and moving upward.

Correct Answer is B

Explanation

A. Cleanse the insertion site of the drain using a circular motion toward the center: Proper technique involves cleaning from the least contaminated area (the center) outward to the surrounding skin, not toward the center, to prevent introducing pathogens into the wound.

B. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation helps remove debris and exudate without damaging tissue or disrupting healing. It is a safe and effective method for cleansing an abdominal incision.

C. Irrigate the wound using a 10-mL syringe: Using a small syringe can create high-pressure flow, which may traumatize tissue. Larger volume syringes (e.g., 30–60 mL) with controlled, low-pressure flow are recommended for wound irrigation.

D. Cleanse the wound starting at the bottom and moving upward: Wound cleaning should proceed from the least contaminated area (top or center of the incision) toward more contaminated areas (periphery) to reduce the risk of introducing bacteria into the wound.

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A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

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A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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