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Terms in this set (21)
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Maintain the client on bed rest.
The client should remain on best rest to decrease the risk of DISLODGING
the clot, which could cause a pulmonary embolism.
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which statement should the nurse include?
"You should leave the diaphragm in place for at least 6 hours after intercourse."
No oil-based product lubricant with diaphragms, weakens the rubber.
Empty bladder before inserting diaphragm.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which finding should the nurse report as a potential complication?
Leakage of fluid from the vagina.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening.
"Ensure that the newborn has been receiving feedings for 24 hours PRIOR to obtaining the specimen."
Newborn screening mandated by law, do not need informed consent prior to obtaining newborn screening specimen.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which finding to report?
BUN 25 mg/dL.
This is an elevated BUN, should report this because it may indicate dehydration.
A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions to include?
"You should get a 2-hour oral glucose tolerance test in 6 to 12 weeks."
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?
A reduction in respiratory distress in the NEWBORN.
Betamethasone is a glucocorticoid that is given to stimulate FETAL LUNG MATURITY and prevent respiratory distress in the PRETERM NEWBORN.
A nurse is teaching a client who is in preterm labor about terbutaline (A TOCOLYTIC). Which of the following indicates understanding?
"I will have blood tests because my potassium might decrease."
An adverse effect of the tocolytic medication TERBUTALINE is hypokalemia.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory values should the nurse report?
Platelets 50,000/mm3.
A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this.
A nurse on the postpartum unit is caring for a client following cesarean birth. Which assessment?
Amount of lochia.
Greatest risk to the cesarean birth client is bleeding and postpartum hemorrhage.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which statement?
"I should take 600 micrograms of folic acid each day."
A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider.
Headache that is unrelieved by analgesia.
A headache that is unrelieved by analgesia may indicate preeclampsia.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which?
Determine respiratory functions.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position.
Apply sacral counter pressure.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs.
Protect the client's head and feet from cold air.
A nurse is performing a physical assessment of a newborn. Which should the nurse expect?
-A heart rate of 154/min.
-A respiratory rate of 58/min.
-A weight of 2.6kg (5 lb, 12 oz).
Normal HR newborn: 110-160/min.
Normal temp
newborn: 97.7-99.5.
Normal resp newborn: 30-60/min.
Normal length newborn: 45-55cm.
Normal weight newborn: 2.5-4kg (5.5-8.8lb).
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation.
FHR 152/min. Normal FHR is 110-160. Same with newborn HR.
Fundal height from weeks 18-32 should be week of gestation plus or minus 2.
E.g. week 18 = fundal height should be between
16-20 cm.
A nurse is planning care for a client who is in labor and is to have an amniotomy.
Temperature.
Greatest risk for a client following amniotomy is infection.
Amniotomy is the artificial rupturing of membranes.
A nurse is caring for a client who is at 36 weeks gestation and has a prescription for an amniocentesis.
To locate a pocket of fluid.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score.
Minimal arm recoil.
A nurse is teaching a client who is pregnant about managing nausea and vomiting.
"Eat high-carbohydrate foods."
Water/fluids in between meals.
Foods serve at cool
temperatures.
Avoid brushing her teeth after eating to prevent triggering gag reflex.
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