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.

Nursing Test Bank

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Correct Answer is C

Explanation

A. When placental site has healed: While the healing of the placental site is important for overall postpartum recovery, menstruation typically resumes after other factors, such as hormonal changes, are regulated, and this is not directly tied to the healing of the site.

B. Four weeks after birth: It is uncommon for menstruation to resume just four weeks after birth. Most women, especially those who are not breastfeeding, may have their first postpartum period a bit later.

C. Six to eight weeks after birth: The typical time for menstruation to return is around six to eight weeks postpartum, although it may vary depending on the individual and whether the woman is breastfeeding or not. Non-breastfeeding women often resume menstruation sooner.

D. When ovulation resumes: Ovulation is a key factor in the return of menstruation, but it is not always directly tied to a specific timeline, and it can vary. For many women, menstruation resumes around six to eight weeks postpartum, although ovulation may occur earlier.

A. Confer with the healthcare provider about a different course of antibiotics. B. Determine if the client's sexual partner received treatment for chlamydia. C. Inquire further about all sexual encounters and any other sexual activity. D. Ask the client if the complete course of antibiotics was completed.

Correct Answer is B

Explanation

A. Confer with the healthcare provider about a different course of antibiotics: While this may be necessary if treatment failure is confirmed, the first step is to evaluate whether the sexual partner was treated, as reinfection is common if the partner was not also treated.
B. Determine if the client's sexual partner received treatment for chlamydia: It is critical to ensure that the sexual partner has been treated for chlamydia as well. If the partner has not been treated, the client could have been reinfected, leading to ongoing symptoms despite completing the antibiotic regimen.
C. Inquire further about all sexual encounters and any other sexual activity: While understanding sexual history is important, the client explicitly stated she is maintaining a "monogamous relationship." the primary focus should be on ensuring that the partner was treated.
D. Ask the client if the complete course of antibiotics was completed: The client was treated with "azithromycin IM." Azithromycin for chlamydia is typically a single dose. The reinfection is more likely from an untreated partner, causing of the persistent symptoms.

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Body System	Nurses Notes and Flow Sheet
Respiratory	Respirations 16 breaths/minute Oxygen saturation of 89% Several deep breaths
Integumentary	Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm
Circulatory	Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 mL/hr
Genital/Urinary	Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

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

A postpartum client who is giving her new baby formula feedings asks the nurse when she should expect to start menstruating again. Which information should the nurse tell the client?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

The nurse is preparing to teach a class on breast self-examination. In describing the "at-risk" individual, the nurse should describe which woman as having the highest risk of developing breast cancer?

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

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.

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.

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having sex with someone who had many partners. Which response should the nurse provide?

Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.

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.