A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The... [Show More] nurse should contact the provider regarding which of the following prescriptions? - The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection.
A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The nurse should administer hepatitis B immunoglobulin 0.5 mL IM.
A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the following instructions should the nurse include in the teaching? - The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy.
A nurse is assessing a client who is in labor and notes early decelerations on the fetal monitor. Which of the following findings should the nurse identify as a possible cause of the early decelerations? - The nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. Early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations.
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? - Take photos of the newborn to give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket).
A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior? - Lays the newborn across her lap and gently sways.
This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? - Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.) - Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping.
Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.
A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? - Room-sharing is recommended during the first few weeks. This allows the parents to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.
A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? - When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers? - Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with her palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? - The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer
A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue with the client's decision. Which of the following actions should the nurse manager take? - The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced [Show Less]
