Family History: breast cancer, heart disease. Allergy: Penicillin.

Multiple sexual partners.

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation.

Which of the following actions should the nurse take?

Administer rubella vaccine.

Administer ceftriaxone IM.

Obtain a blood culture.

Obtain a maternal serum alpha-fetoprotein specimen.

Answer and Explanation

The Correct Answer is D

The nurse should obtain a maternal serum alpha-fetoprotein (MSAFP) specimen for a client at 12 weeks of gestation.

MSAFP is a screening tool used to identify fetal neural tube defects (NTDs) such as spina biﬁda and anencephaly.

Elevated levels of MSAFP indicate an increased risk for NTDs, while low levels indicate an increased risk for chromosomal abnormalities such as Down syndrome.

Administering rubella vaccine (A) is contraindicated during pregnancy as it is a live vaccine and can cause fetal harm.

Administering ceftriaxone IM (B) and obtaining a blood culture (C) are not indicated based on the information provided about the client.

The client's allergy to penicillin is not relevant to the nurse's immediate action.

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Correct Answer is A

Explanation

A. The nurse should monitor for chorioamnionitis, which is an infection of the amniotic sac and ﬂuid.

The other choices are not potential complications of gonorrhea:

B. Vaginal laceration during birth is not a complication of gonorrhea.

C. Oligohydramnios is not a complication of gonorrhea.

D. Excessive bleeding after birth is not a complication of gonorrhea.

A. Hypertension. B. Respiratory rate 16/min. C. Urine output 20 mL/hr. D. Hyperglycemia. E. Hyperglycemia.

Correct Answer is C

Explanation

This can be a sign of magnesium toxicity and should be reported to the provider.

Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.

Choice B is incorrect because a respiratory rate of 16/min is within normal range.

Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.

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Family History: breast cancer, heart disease. Allergy: Penicillin. Multiple sexual partners. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Correct Answer is C

Explanation

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A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Family History: breast cancer, heart disease. Allergy: Penicillin.

Multiple sexual partners.

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation.

Which of the following actions should the nurse take?