High Risk Pregnancy
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?
A) urinary output of 20 mL per hour
B) respiratory rate of 10 breaths/minute
C) deep tendons reflexes 2+
D) difficulty in arousing
Answer: C
Rationale: With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.
A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn.
Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn?
A) substance use disorder
B) diabetes
C) preeclampsia
D) infection
Answer: B
Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
A) +2 station
B) 0 station
C) -2 station
D) crowning
Answer: C
Rationale: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.
Which class of oral antihyperglycemic medications is first line class Tx of DM2?
Biguanides (ex, Metformin). Diabetes Pharm PPT Slide 11
True or False:
Narrow-spectrum antibiotics can only target gram-negative species of bacterial pathogens.
Answer: False
Rationale: Some narrow-spectrum drugs only target gram positive bacteria, but others target only gram-negative bacteria. If the pathogen causing infection has been identified in a culture and sensitivity test, it is best to use a narrow-spectrum antimicrobial and minimize collateral damage to the normal micro bacteria.
Ref: xanedu pharmacology book, p.86 (Broad-Spectrum versus Narrow-Spectrum Antimicrobials)
A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
A) use of oral contraceptives for 5 years
B) ovarian cyst 2 years ago
C) recurrent pelvic infections
D) heavy, irregular menses
Answer: C
Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy.
A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:
A) cardiac distress
B) respiratory alkalosis
C) bronchial pneumonia
D) respiratory distress
Answer: D
Rationale: Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87%. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time.
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30% and contractions occurring every 7-8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
A) Latent phase of the first stage
B) Active phase of the first stage
C) Pelvic phase of second stage
D) Early phase of third stage
Answer: A
Rationale: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.
4 sites for subcutaneous insulin administration?
Abdomen, upper arms, thighs, buttocks. Important to ROTATE SITES. Brunner pg. 1509, figure 46-5. Diabetes Pharm PPT Slide 44
Which class of medications helps loosen sputum (mucus) and thin bronchial secretions to make coughs more productive?
A) Beta-2 Agonists
B) Antitussives
C) Expectorants
D) Decongestants
Answer: C
Rationale: Expectorants reduce the viscosity of tenacious secretions by irritating the gastric vagal receptors that stimulate respiratory tract fluid, thus increasing the volume but decreasing the viscosity of respiratory tract secretions. Indication for Use Expectorants are used for a productive cough and for loosening mucus from the respiratory tract.
Ref: xanedu pharmacology book, p.211 (EXPECTORANTS)
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
A) "Why are you crying?"
B) "Will a pill help your pain?"
C) "I’m sorry you lost your baby."
D) "A baby still wasn't formed in your uterus."
Answer: C
Rationale: Telling the client that the nurse is sorry for the loss acknowledges the loss to the woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client has.
A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care?
A) keeping the newborn in the supine position
B) covering the newborn's eyes while under the bililights
C) ensuring that the newborn is covered or clothed
D) reducing the amount of fluid intake to 8 ounces daily
Answer: B
Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights.
The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories.
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?
A) Extent of opening to its widest diameter
B) Degree of thinning
C) Passage of the mucous plug
D) Fetal presenting part
Answer: B
Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
This class of oral antihyperglycemic medications carries a risk for being hepatotoxic and has a black box warning for Heart Failure?
Thiazolidinediones. Monitor liver labs, contraindicated in pts with HF & fluid retention. Diabetes Pharm PPT Slide 17
During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurse’s best response?
A) The vaccine causes an antibody response in the body
B) The vaccine responds to an infection in the body after it occurs
C) The vaccine is similar to an antibiotic that is used to treat an infection
D) The vaccine actively attacks the microorganism
Answer: A
Rationale: Vaccines are an antigen preparation that produces an antibody response in a human to protect him or her from future exposure to the vaccinated organism. A vaccine does not respond to an infection after it occurs; it does not act like an antibiotic and does not actively attack the microorganism.
Ref: ch.66 - Brunner Suddarth Medical Surgical Nursing (15th by Hinkle)
A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply.
A) low whimpering cry
B) hypertonicity
C) lethargy
D) excessive sneezing
E) overly vigorous sucking
F) tremors
Answer: B, D, F
Rationale: Signs and symptoms of withdrawal, or neonatal abstinence syndrome, include: irritability, hypertonicity, excessive and often high-pitched crying, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures.
A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply.
A) BMI 17.5
B) blood pressure 110/70 mm Hg
C) prenatal history
D) homelessness
E) age
F) prenatal care
Answer: A, C, D, F
Rationale: The key to identifying a newborn with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a newborn at risk. These factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of previous preterm birth.
A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?
A) Check the pH to ensure the fluid is amniotic fluid
B) Prepare to administer an antibiotic
C) Notify the health care provider about possible meconium
D) Check the maternal heart rate
Answer: C
Rationale: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.
What A1C level indicates the need to start insulin therapy?
Equal to or greater than 9.5%. Oral antihyperglycemics no longer effective alone, pt will need insulin therapy. Other indications include, random glucose >300mg/dL, fasting glucose >250mg/dL, symptoms of hyperglycemia, and presence of urine ketones. Diabetes Pharm PPT Slide 30
A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action?
A) This medication will reduce the amount of acid secreted in your stomach
B) This medication will make the lining of your stomach more resistant to damage
C) This medication will specifically address the pain that accompanies peptic ulcer disease
D) This medication will help your stomach lining to repair itself
Answer: A
Rationale: Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.
A pregnant woman with chronic hypertension is entering her second trimester. The nurse is providing anticipatory guidance to the woman about measures to promote a healthy outcome. The nurse determines that the teaching was successful based on which client statements? Select all that apply.
A) "I will need to schedule follow-up appointments every 2 weeks until I reach 32 weeks' gestation."
B) "I should try to lie down and rest on my left side for about an hour each day."
C) "I will start doing daily counts of my baby's activity at about 24 weeks' gestation."
D) "I will need to have an ultrasound at each visit beginning at 28 weeks' gestation."
E) "I should take my blood pressure frequently at home and report any high readings."
Answer: B, C, E
Rationale: The woman with chronic hypertension will be seen more frequently (every 2 weeks until 28 weeks' gestation and then weekly until birth) to monitor her blood pressure and to assess for any signs of preeclampsia. At approximately 24 weeks' gestation, the woman will be instructed to document fetal movement. At this same time, serial ultrasounds will be prescribed to monitor fetal growth and amniotic fluid volume. The woman should also have daily periods of rest (1 hour) in the left lateral recumbent position to maximize placental perfusion and use home blood pressure monitoring devices frequently (daily checks would be preferred), reporting any elevations.
A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply.
A) There is flaccid muscle tone of the affected limb
B) Respiration rate is 52 breaths per minute
C) Heart rate is 180 beats per minutes
D) Oxygen saturation level is 88%
E) The infant has facial grimacing and quivering chin
Answer: C, D, E
Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the normal blood pressure, pulse, and respiration are noted.
Normal HR:
Normal RR:
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
A) At 32 weeks' gestation and immediately before discharge
B) 24 hours before birth and 24 hours after birth C. in the first trimester and within 2 hours of birth
C) In the first trimester and within 2 hours of birth
D) A 28 weeks' gestation and again within 72 hours after birth
Answer: D
Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.
What are 5 guidelines for sick day rules?
Take insulin or ordered oral agent as ordered, check BG & ketones Q2-4hrs, Report altered levels to HCP, Eat 10-15g of carbs q1-2hrs, Fluids Q15-30min. Brunner Chart 46-9, Diabetes Pharm PPT Slide 47
A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?
A) Take the medication on an empty stomach
B) Take up to one extra dose per day if stomach pain persists
C) Take at bedtime to mitigate the effects of drowsiness
D) Avoid drinking alcohol while taking the drug
Answer: D
Rationale: Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.