Exhibits

The nurse reviews the standing prescriptions for laboring mothers and determines the best plan of care. Which intervention(s) would the nurse initiate? Select all that apply.

Initiate IV oxytocin at 6 milliunits/minute

Place peripheral IV and administer IV lactated Ringers at 125 mL/hour

Obtain consult for a cesarean delivery

Administer IV bolus of 5 grams of magnesium sulfate

Initiate seizure precautions, limit visitors

Administer oxygen 2 L/minute via nasal cannula

Answer and Explanation

Correct Answer : B,D,E

A. Initiate IV oxytocin at 6 milliunits/minute: Oxytocin is not necessary as the patient is not in labor. Administering it could increase contractions, which is not needed and may complicate the patient's condition.

B. Place peripheral IV and administer IV lactated Ringers at 125 mL/hour: IV fluids help maintain blood volume and circulation, which is essential for managing pre-eclampsia and preventing complications like stroke or organ failure.

C. Obtain consult for a cesarean delivery: A cesarean delivery is not the immediate priority. Managing pre-eclampsia and stabilizing the patient is the main focus before deciding on delivery options.

D. Administer IV bolus of 5 grams of magnesium sulfate: Magnesium sulfate prevents seizures in pre-eclampsia or eclampsia. The patient’s clonus and hyperreflexia indicate she is at risk, making this a critical intervention.

E. Initiate seizure precautions, limit visitors: The patient is at risk for eclampsia, so seizure precautions are necessary. Limiting visitors helps reduce external stimuli that could trigger a seizure.

F. Administer oxygen 2 L/minute via nasal cannula: Oxygen is not needed unless there are signs of respiratory distress. The focus should be on managing pre-eclampsia and preventing seizures with magnesium sulphate.

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Correct Answer is D

Explanation

A. This gene is passed down only to male children: An X-linked dominant inheritance disorder can be passed to both male and female children. are at risk for inheriting an X-linked dominant gene, but they are not the only offspring who can inherit the gene.

B. This gene is passed down only to female children: X-linked dominant inheritance disorders can be passed to both male and female children. Sons inherit the X chromosome from their mother, and daughters inherit one X chromosome from each parent.

C. There is a 100% chance of passing this gene on to all children: A 100% chance of passing the gene does not occur in X-linked inheritance disorders. In heterozygous conditions, the mother has a 50% chance of passing the gene to each child, whether male or female.

D. There is a 50% chance of passing this gene on to all children: In X-linked dominant inheritance, a heterozygous mother has a 50% chance of passing the gene to each child, regardless of the child’s sex.

A. One-hour glucose screen. B. Repeat HIV test. C. Multiple marker screening. D. Direct Coombs' test.

Correct Answer is A

Explanation

A. One-hour glucose screen: The one-hour glucose screen is typically performed at 24-28 weeks gestation to screen for gestational diabetes. This is a standard test for all pregnant women during this time frame, regardless of ethnicity, and should be included in the client teaching.
B. Repeat HIV test: While HIV screening is important during pregnancy, a repeat HIV test at 28 weeks is not typically recommended for all women unless they are at high risk or have specific risk factors.
C. Multiple marker screening: This screening is usually done earlier in pregnancy, typically between 15-20 weeks, to assess the risk of certain fetal conditions like Down syndrome and neural tube defects. It is not performed at 28 weeks.
D. Direct Coombs' test: The Direct Coombs' test is typically performed on newborns, not on pregnant women, to check for hemolytic disease. However, Rh-negative women are often screened with the indirect Coombs' test at 28 weeks to check for antibodies, not the direct Coombs' test.

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Exhibits The nurse reviews the standing prescriptions for laboring mothers and determines the best plan of care. Which intervention(s) would the nurse initiate? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the genetic test report for a pregnant client with a history of several spontaneous abortions. The results show the client has a heterozygous x-linked dominant inheritance disorder. How should the nurse explain the results to the client?

Correct Answer is D

Explanation

The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal laboratory assessment, prescribed at 28-weeks, should the nurse include in client teaching?

Correct Answer is A

Explanation

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

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How should the nurse plan to position a client who has just undergone a radical mastectomy?

Which content should the nurse plan to include in a nutrition class for pregnant adolescents? Select all that apply.

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage. Which is this client's gravidity?

A client who is receiving oxytocin to augment early labor begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

Exhibits

The nurse reviews the standing prescriptions for laboring mothers and determines the best plan of care. Which intervention(s) would the nurse initiate? Select all that apply.