,
,1. A nurse is assessing a client who is at 33 weeks of gestation. Which
of the following findings should the nurse report to the provider?
a. Epigastric pain: The nurse
should notify the provider
of the client's report of
epigastric pain because
this is a manifestation of
preeclampsia. Other
findings the nurse should
report include severe
headache, blurred vision,
confusion, nausea and
vomiting, and decreased
urinary output.
b. Leukorrhea: Leukorrhea,
or vaginal discharge, is an
expected finding
throughout pregnancy.
Leukorrhea increases
during pregnancy due to
hypertrophy of the cervix,
which increases the
amount of mucus secreted
from the vagina.
c. Excessive salivation:
Ptyalism, or excessive
, salivation, is an expected
finding in pregnancy.
Increased levels of
estrogen cause an
increase in the production
of saliva.
d. Darkening of the skin on
the face:
Hyperpigmentation on the
face, or melasma, is an
expected finding during
pregnancy. The anterior
pituitary gland increases
the production of
melanocyte-stimulating
hormone, causing an
increase in pigmentation of
the skin.
2. A nurse is assessing a newborn following a circumcision 48 hr ago.
The nurse should identify that yellow exudate covering the newborn's glans
penis indicates which of the following?
a. Wound infection: Infected
circumcision wounds
appear swollen with a
purulent discharge.
b. Ulceration: Yellow exudate
following a circumcision is
not a manifestation of an
ulceration.
c. Exposure to urine: Yellow
exudate is not a
manifestation resulting
, from the wound being
exposed to urine.
d. Healing: After 24 hours,
yellow exudate usually
forms over the glans penis
and remains for the
next 2 to 3 days. It sometimes forms a crust, which is plain
expected. The nurse should ex that
the yellow film the guardians will see is granulation tissueThe
as the circumcision heals.
guardians should not remove this tissue.
3. A nurse is developing a plan of care for a client who is in the latent
phase of labor. Which of the following interventions should the nurse
include in the plan to manage the client's pain?
a. Encourage the client to
listen to music: During the
latent phase of labor, the
nurse should implement
nonpharmacological
strategies to encourage
relaxation and provide
pain relief. There are a
wide variety of cutaneous
and sensory measures
that are simple to
implement during this
stage of labor, such as
music, rocking, breathing
techniques, walking and
application of hot or cold
packs.
,b. Instruct the client how to
use biofeedback:
Biofeedback can be an
effective method to reduce
the discomfort of labor by
promoting self-awareness
and relaxation. However,
the client must have
received instruction and
practiced this technique
prior to labor for it to be
effective.
c. Administer fentanyl 100
mcg every hour via
intermittent IV
bolus…Fentanyl is an
opioid agonist analgesic
that enhances a client's
ability to rest between
contractions. However,
opioids can also inhibit
uterine contractions and
prolong labor. Therefore,
avoid administration of
opioid analgesia until a
client reaches the active
phase of labor or cervical
dilation of at least 4 cm.
d. Request the provider
administer a pudendal
nerve block….A pudendal
nerve block relieves pain
in the lower vagina and
perineum during the
second or third stage of
labor. It provides
, anesthesia for episiotomy
or repair of lacerations
following birth.
4. A nurse is reviewing the laboratory results for a postpartum client
who is receiving warfarin for deep-vein thrombosis. Which of the following
laboratory tests should the nurse monitor?
a. WBC count: The nurse
should monitor the WBC
count for clients who have
conditions such as
chorioamnionitis.
However, it is not necessary for the nurse to monitor this level for a
client who is receiving warfarin therapy.
b. International normalized
ratio (INR): The nurse
should monitor the INR of
a client who is taking
warfarin. Prothrombin
time (PT) is also measured
to regulate warfarin
therapy. However, PT
values are more difficult to
interpret. INR is
determined by multiplying
the PT by a correction
factor based on the
specific thromboplastin
preparation used for the
test, as a way of equalizing
laboratory-to-laboratory
variations.
, c. Plasminogen levels:
Plasminogen is fibrinolytic
and is usually elevated
during pregnancy.
However, it is not
necessary for the nurse to
monitor this level for a
client who is receiving
warfarin therapy.
d. Activated partial
thromboplastin time
(aPTT): The nurse should
review aPTT if client is
receiving heparin.
5. A nurse is reviewing the medical record of a client who has
preeclampsia prior to administering labetalol. For which of the following
findings should the nurse withhold the medication?
a. Uric acid 7.5 mg/dL: The
nurse should identify that a
uric acid level of 7.5 mg/dL
is above the expected
reference range of 2.7 to
7.3 mg/dL for a client who
is pregnant. Elevated uric
acid is a manifestation of
preeclampsia and is
caused by decreased renal
perfusion. However, an
elevated uric acid level is
not a contraindication for
the administration of
labetalol, an
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