Question

A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?

Answer 1

Correct Answers:

Urinalysis for ketones.

Rationale :

🟧 Urinalysis for ketones is the priority test because it indicates the severity of dehydration and malnutrition from persistent vomiting.

🟧 Ketones in urine reflect fat breakdown due to prolonged inability to retain nutrients.

🟧 Identifying ketosis helps guide IV fluid and nutritional therapy.

🟧 Early detection prevents progression to more serious complications like electrolyte imbalance.

🟧 This test provides immediate, actionable data for safe management.

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Answer 2

Correct Answers:

Elevate the client’s legs.

Rationale :

🟧 Leg elevation improves venous return and increases blood flow to the brain and vital organs in postpartum clients showing signs of shock.

🟧 Diaphoresis, clammy skin, rapid pulse, and weakness suggest hypovolemia or orthostatic hypotension.

🟧 Prompt positioning may help prevent fainting or worsening hypotension.

🟧 Elevating legs is a noninvasive, immediate nursing intervention while other assessments or treatments are prepared.

🟧 Ensures patient safety while root causes are addressed.

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Answer 3

Correct Answers:

Offer an ice pack to the client during the first 24 hours.

Rationale :

🟧 Ice packs are the best first-line nonpharmacological intervention for perineal pain and swelling after vaginal delivery.

🟧 Applying cold reduces inflammation and numbness, providing rapid pain relief.

🟧 This method is most effective within the first 24 hours postpartum.

🟧 Using ice before turning to medication avoids unnecessary drug exposure.

🟧 It is simple, safe, and effective in most postpartum settings.

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Answer 4

Correct Answers:

Oral contraceptives decrease the risk for endometrial cancer.

Rationale :

🟧 Oral contraceptives provide a protective effect against endometrial (and ovarian) cancer by regulating hormones.

🟧 This is a widely known secondary health benefit of combined hormonal contraceptive use.

🟧 Teaching clients about this additional benefit may support informed contraceptive choices.

🟧 Decreased risk is especially important for clients with family history of gynecologic malignancy.

🟧 The effect is not shared by all contraceptive methods, so education must be specific.

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Answer 5

Correct Answers:

You should use a breast pump if you plan to return to work.

Rationale :

🟧 Using a breast pump helps empty the breasts, preventing milk stasis and mastitis.

🟧 Pumping maintains milk supply and reduces infection risk when direct breastfeeding isn’t possible.

🟧 This is especially vital for mothers returning to work or separated from their infants.

🟧 Regular emptying—by feeding or pumping—minimizes bacterial overgrowth.

🟧 Teaching about pumps is part of comprehensive postpartum support.

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Answer 6

Correct Answers:

Administer the medication within 72 hours after birth.

Rationale :

🟩 Rh(D) immune globulin must be given within 72 hours after delivery to prevent Rh sensitization in an Rh-negative mother with an Rh-positive baby.

🟩 This time frame ensures the mother’s immune system does not develop antibodies against Rh-positive cells.

🟩 Correct timing reduces risk of hemolytic disease in future pregnancies.

🟩 It is administered IM, but the site is not the abdomen postpartum—typically the deltoid or gluteal muscle.

🟩 The nurse should always check maternal and newborn Rh status and ensure the client is a candidate.

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Answer 7

Correct Answers:

Amoxicillin.

Rationale :

🟩 Amoxicillin is a safe and effective antibiotic for treating chlamydia in pregnancy.

🟩 Tetracycline is contraindicated due to effects on fetal teeth/bone.

🟩 Acyclovir is for herpes; metronidazole is for trichomoniasis or BV, not chlamydia.

🟩 Treating chlamydia is crucial to prevent preterm labor, PROM, and neonatal infection.

🟩 Early treatment ensures the best outcomes for both mother and baby.

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Answer 8

Correct Answers:

Double vision.

Rationale :

🟩 Double vision (diplopia) is a potential sign of severe preeclampsia or neurological complications.

🟩 It is an urgent symptom, unlike mild edema or minor blood pressure elevations at this gestational age.

🟩 Prompt reporting and assessment prevent maternal and fetal complications.

🟩 Visual disturbances during pregnancy are always taken seriously.

🟩 The nurse should educate all clients to report vision changes immediately.

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Answer 9

Correct Answers:

Supine.

Rationale :

🟩 The supine position is safest for all newborns to sleep—reducing the risk of sudden infant death syndrome (SIDS).

🟩 Placing babies on their back is the #1 recommendation in all safe sleep guidelines.

🟩 Lateral and prone positions increase the risk of airway obstruction and SIDS.

🟩 Nurses must reinforce this practice with every parent at discharge.

🟩 Consistent safe sleep messaging saves lives.

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Answer 10

Correct Answers:

“You will press the provided button when you feel the baby moving during the test.”.

Rationale :

🟩 During a nonstress test, the client tracks fetal movements by pressing a button, which marks the tracing for heart rate correlation.

🟩 There are no restrictions on food/drink before this test.

🟩 The client should not lie flat throughout; a tilted position prevents hypotension.

🟩 No IV medications are used; it is noninvasive.

🟩 Accurate teaching supports effective, reassuring testing.

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QLexNursing

1 :
A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?

2 :
A nurse is assisting with the care of a client who was admitted to the postpartum unit. The client is diaphoretic, skin is clammy, pulse is rapid and strong, respirations are shallow. he client reports headache, nausea, and feeling weak. Which of the following actions should the nurse take

3 :
A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

4 :
A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?

5 :
A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding. Which of the following instructions should the nurse include?

6 :
A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia. Which of the following medications should the nurse plan to administer?

8 :
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago. Which of the following findings should the nurse report to the provider?

9 :
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

10 :
A nurse in a provider’s office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?

QLexNursing

1 : A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?

2 : A nurse is assisting with the care of a client who was admitted to the postpartum unit. The client is diaphoretic, skin is clammy, pulse is rapid and strong, respirations are shallow. he client reports headache, nausea, and feeling weak. Which of the following actions should the nurse take

3 : A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

4 : A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?

5 : A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding. Which of the following instructions should the nurse include?

6 : A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum. Which of the following actions should the nurse take?

7 : A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia. Which of the following medications should the nurse plan to administer?

8 : A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago. Which of the following findings should the nurse report to the provider?

9 : A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

10 : A nurse in a provider’s office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?

1 :
A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?

2 :
A nurse is assisting with the care of a client who was admitted to the postpartum unit. The client is diaphoretic, skin is clammy, pulse is rapid and strong, respirations are shallow. he client reports headache, nausea, and feeling weak. Which of the following actions should the nurse take

3 :
A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

4 :
A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?

5 :
A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding. Which of the following instructions should the nurse include?

6 :
A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia. Which of the following medications should the nurse plan to administer?

8 :
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago. Which of the following findings should the nurse report to the provider?

9 :
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

10 :
A nurse in a provider’s office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?