1. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the
... [Show More] nurse expect?
a. Reports increased urinary output
i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of
thirst, abdominal pain, constipation, drowsiness, and headaches are
manifestations of hyperglycemia. Other manifestations include weak rapid
pulse, fruity breath odor, urine positive for sugar and acetone, and a blood
glucose level greater than 200 mg/dL.
b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed,
dry skin is a manifestation of hyperglycemia.
c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A
report of dim vision is a manifestation of hyperglycemia.
d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid
breathing is a manifestation of hyperglycemia.
2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which
of the following actions should the nurse take?
a. Administer penicillin G 2.4 million units IM to the client. The nurse should →
administer penicillin G 2.4 million units IM to a client who has syphilis.
b. Instruct the client to schedule an annual pelvic examination. The nurse should
instruct the client to schedule a pelvic examination every 6 months.
c. Tell the client she will start medication for HIV immediately after delivery. ➔
The nurse should tell the client that treatment for HIV will be during the
prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such
as zidovudine, triple-drug antiretroviral therapy (ART), or highly active
antiretroviral therapy (HAART) during pregnancy have been reported to
decrease the transmission of the virus to the newborn.
d. Report the client's condition to the local health department.
i. MY ANSWER. The nurse should report the condition to the local health
department. HIV is one of the conditions on the list of Nationally
Notifiable Infectious Conditions that is required to be reported.3. A nurse is providing teaching for a client who has a new prescription for combined oral
contraceptives. Which of the following findings should the nurse include as an adverse
effect of the medication?
a. Depression.
i. MY ANSWER. The nurse should instruct the client that depression is a
common adverse effect of combined oral contraceptives. Other common
adverse effects of the medication include amenorrhea, weight gain,
headache, nausea, breakthrough bleeding, and breast tenderness.
b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a
common adverse effect of the medication.
c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect
of combined oral contraceptives.
d. Urticaria. Urticaria is not a common adverse effect of combined oral
contraceptives.
4. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new
prescription for misoprostol. Which of the following instruction should the nurse include
in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
i. MY ANSWER. The nurse can administer oxytocin no sooner than 4 hr
after the last dose of misoprostol. Oxytocin can be administered following
misoprostol for clients who have cervical ripening and have not begun
labor.
b. "You will need a full bladder prior to the insertion of the medication." The nurse
should instruct the client to void prior to the administration of the medication.
c. "Remain in a side-lying position for 15 minutes after the medication is inserted."
The nurse should instruct the client to remain in a side-lying position for 30 to 40
min after the insertion.
d. "An antacid will be given 20 minutes prior to the insertion of the medication."
The nurse should avoid administering aluminum hydroxide and
magnesiumcontaining antacids with misoprostol.
5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of
the following actions should the nurse take?
a. Administer antiviral medication. Currently, there are no antiviral medications
available to treat fifth disease.
b. Schedule an ultrasound examination.
i. MY ANSWER: The nurse should schedule serial ultrasound examinations
to monitor the fetus during the pregnancy to detect the possible
development of fetal hydrops. Also, the virus can cause miscarriage,
intrauterine growth restriction, fetal anemia, or stillbirth.c. Administer Haemophilus influenzae type b vaccine. The Haemophilus influenzae
type b vaccine is given during infancy and childhood to protect against multiple
infections caused by Haemophilus influenzae type b, not fifth disease. Currently,
there are no vaccines to protect against fifth disease.
d. Schedule an indirect Coombs' test. An indirect Coombs' test determines whether
the client has antibodies to the Rh antigen. The titer determines the prenatal
client's sensitization and if there is Rh incompatibility.
6. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which
of the following techniques should the nurse use to help minimize the pain of the
procedure for the newborn?
a. Apply a cool pack for 10 min to the heel prior to the puncture. A cool pack will
constrict the blood vessels, making it more difficult to obtain an adequate
specimen. The nurse should apply a warm pack prior to the puncture.
b. Request a prescription for IM analgesic. The pain experienced from a heel stick is
too brief to warrant risking the adverse effects of parenteral analgesia.
c. Use a manual lance blade to pierce the skin. A spring-loaded, automatic puncture
device is recommended to minimize pain by ensuring that the depth of the
puncture is not too deep, avoiding injury to the newborn.
d. Place the newborn skin to skin on the mother's chest.
i. MY ANSWER: Placing the newborn skin to skin on the mother's chest is
an effective technique to significantly decrease the newborn's pain level
and anxiety. The nurse should implement this technique before, during,
and after the procedure.
7. A nurse is performing a vaginal examination on a client who is in labor and observes the
umbilical cord protruding from the vagina. After calling for assistance, which of the
following actions should the nurse take?
a. Insert two gloved fingers into the vagina and apply upward pressure to the
presenting part.
i. MY ANSWER: The nurse should quickly apply gloves and insert two
fingers into the vagina toward the cervix, exerting upward pressure onto
the presenting part to relieve umbilical cord compression and increase
oxygenation to the fetus.
b. Wrap the visible cord tightly with sterile, dry gauze. The nurse should wrap the
visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride
solution, rather than with sterile, dry gauze.
c. Apply oxygen to the client at 2 L/min via nasal cannula. The nurse should apply
oxygen to the client at 8 to 10 L/min via nonbreather mask.d. Place the client in the lithotomy position and apply fundal pressure. The nurse
should place the client into a modified Sims position, knee-chest position, or
extreme Trendelenburg to attempt to relieve the compression of the umbilical
cord.
8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected
placental abruption. Which of the following laboratory tests should the nurse expect the
provider to prescribe?
a. Kleihauer-Betke test
i. MY ANSWER: The nurse should expect the provider to prescribe a
Kleihauer-Betke test for a client who has suspected placental abruption to
determine if fetal blood is in maternal circulation. This test is useful to
determine if Rho-(D) immune globulin therapy should be administered to
a client who is Rh-negative.
b. Progesterone serum level. A progesterone serum level helps to determine if a
client is pregnant and if the pregnancy is ectopic.
c. Lecithin/sphingomyelin (L/S) ratio. Lecithin/sphingomyelin (L/S) ratio is done as
a part of an amniocentesis to evaluate fetal lung maturity.
d. Maternal Alpha-fetoprotein (AFP). Maternal Alpha-fetoprotein (AFP) is a
laboratory test used to assess for neural tube defects or chromosome disorders.
9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For
which of the following complications should the nurse assess?
a. Abruptio placenta
i. MY ANSWER: Cocaine use increases the risk for vasoconstriction and
possible abruptio placenta.
b. Placenta previa. This is not a common complication associated with cocaine use.
c. Preeclampsia. This is not a common complication associated with cocaine use.
d. Maternal bradycardia. This is not a common complication associated with cocaine
use.
10. A nurse is assessing a client who has severe preeclampsia. Which of the following
manifestations should the nurse expect?a. 2+ deep tendon reflexes. The nurse should identify that a client who has severe
preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of
2+ is indicative of an active or expected response.
b. Proteinuria of 200 mg in a 24-hr specimen. The nurse should identify that a client
who has severe preeclampsia can have increased amount of urinary protein that is
greater than 500 mg in a 24-hr specimen.
c. Polyuria. The nurse should identify that a client who has severe preeclampsia can
have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in
24 hr. This is related to decreased perfusion of the kidneys and possible
glomerular damage.
d. Blurred vision
i. MY ANSWER: The nurse should identify that a client who has severe
preeclampsia can have arteriolar vasospasms and decreased blood flow to
the retina which can lead to visual disturbances, such as blurred vision,
double vision, or dark spots in the visual field. [Show Less]