Question

A nurse is planning to administer misoprostol 50 mcg intravaginally for cervical ripening to a client who is at 40 weeks of gestation. Available is misoprostol 200 mcg tablets. How many tablets should the nurse plan to administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

0.25

Rationale :

💎 To determine how many tablets to administer,

Use the formula

Ordered Dose ÷ Available dose per tablet

🖋️ordered dose = 50 mcg

🖋️available dose per tablet = 200 mcg.

💎 Calculation: 50 mcg ÷ 200 mcg

👉= 0.25 tablets.

💎 Misoprostol is a potent medication, so precise dosing is essential to prevent uterine hyperstimulation.

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Answer 2

Correct Answers:

Measure from the upper border of the symphysis pubis to the upper border of the fundus.

Rationale :

🖋️ Fundal height measurement is a key assessment of fetal growth and gestational age.

🖋️ The proper technique is to measure from the upper edge of the symphysis pubis to the top of the uterine fundus in centimeters.

🖋️ The number of centimeters generally correlates with the number of weeks of gestation after 20 weeks.

🖋️ The client should have an empty bladder to avoid skewing the measurement.

🖋️ Positioning should be supine, not lateral, for accuracy and consistency during measurements.

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Answer 3

Correct Answers:

“The diaphragm should be left in place for 4 hours after intercourse."

Rationale :

🔴 A client should empty their bladder before diaphragm insertion to reduce the risk of urinary tract infection (UTI).

🔴 The diaphragm must remain in place for at least 6 hours after intercourse, not just 4.

🔴 Using oil-based lubricants can weaken the rubber, so only water-based lubricants are recommended.

🔴 Applying baby powder is not advised, as it can cause irritation or damage to the material.

🔴 The diaphragm is a barrier contraceptive and must be fitted properly to ensure effectiveness.

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Answer 4

Correct Answers:

History of ovarian cysts

Rationale :

🟤 Migraines with aura are a serious contraindication for estrogen-containing oral contraceptives.

🟤 They significantly increase the risk of ischemic stroke, especially in women who also smoke or have hypertension.

🟤 Clients with migraine without aura may still be eligible depending on other risk factors.

🟤 Conditions like dysmenorrhea or ovarian cysts do not prevent the use of oral contraceptives.

🟤 A thorough medical history and risk assessment is essential before prescribing hormonal contraceptives.

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Answer 5

Correct Answers:

Hand-to-mouth movements
Sucking motions
Rooting reflex

Rationale :

Hand-to-mouth movements:

🟣 This is a common early sign of hunger, indicating the infant is seeking to feed.

🟣 Early cues are preferable to respond to before the baby becomes distressed.

🟣 Recognizing these signs helps promote successful breastfeeding.

Sucking motions:

🟣 Newborns often display sucking behavior when hungry or seeking comfort.

🟣 This reflex is instinctual and an early indicator before crying begins.

🟣 Caregivers should be educated to respond to this cue promptly.

Rooting reflex:

🟣 Stroking the infant’s cheek prompts turning toward the stimulus, preparing for feeding.

🟣 This reflex supports effective latching during breastfeeding.

🟣 It typically fades by 4 months but is essential for feeding readiness.

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Answer 6

Correct Answers:

Monitor fetal heart rate tracings.

Rationale :

🔵 Abruptio placentae involves premature separation of the placenta, risking fetal hypoxia or death.

🔵 Monitoring fetal heart rate provides real-time assessment of fetal well-being.

🔵 Continuous monitoring helps detect signs of distress, such as bradycardia or decelerations.

🔵 It also guides decisions regarding the need for urgent delivery.

🔵 This is a priority action in moderate placental abruption cases.

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Answer 7

Correct Answers:

Administer hepatitis B immune globulin 1M to the newborn.

Rationale :

🟠Newborns born to mothers positive for hepatitis B should receive hepatitis B immune globulin (HBIG) within 12 hours of birth to provide passive immunity.

🟠 HBIG is administered intramuscularly, along with the first dose of the hepatitis B vaccine, to reduce transmission risk.

🟠 Bathing is not delayed for 24 hours unless significant maternal blood or fluid is present; standard precautions are sufficient.

🟠Breastfeeding is safe as long as the infant receives appropriate immunoprophylaxis.

🟠 Airborne precautions are not required for hepatitis B; it is transmitted through blood and body fluids, not airborne particles.

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Answer 8

Correct Answers:

"Plan to spend individual time with your preschooler."

Rationale :

♦️Spending individual time with a preschooler helps prevent feelings of jealousy or neglect after the new sibling arrives.

♦️This maintains the child’s sense of security and connection with the parent.

♦️ Sudden changes like switching sleeping arrangements just before birth can increase anxiety or resentment.

♦️ Involving the child in baby-related tasks, visits, or conversations can help with positive sibling adjustment.

♦️ The nurse should provide family-centered guidance tailored to the child’s developmental stage.

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Answer 9

Correct Answers:

Monitor for clonus.

Rationale :

🟢Clients with preeclampsia should be monitored for signs of neurologic excitability, such as clonus, which may indicate risk of seizures (progression to eclampsia).

🟢Even without severe features, ongoing assessment is essential as the condition can rapidly progress.

🟢Clonus is assessed by dorsiflexing the foot and observing rhythmic oscillations, which reflect central nervous system irritability.

🟢 Early detection allows timely administration of magnesium sulfate if needed for seizure prophylaxis.

🟢 Other interventions like fluid restriction or misoprostol are not indicated unless there's postpartum hemorrhage or fluid overload.

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Answer 10

Correct Answers:

"Check identification badges of staff who enter your room."

Rationale :

⏺️ Newborn security depends on verifying that all staff have correct, matching identification badges.

⏺️ Staff should also be wearing photo ID and matching hospital credentials with banded newborns and parents.

⏺️ Parents should never remove monitoring devices or send the baby out alone, even for routine care.

⏺️Security measures aim to prevent infant abduction, especially within the first few days post-birth.

⏺️ The nurse should teach the parents their role in actively protecting their baby.

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QLexNursing

2 :
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

3 :
A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is reviewing the medical record of a client who is requesting an oral contraceptive for birth control. The nurse should identify which of the following findings as a contraindication for the use of oral contraceptives for this client?

5 :
A nurse is teaching a new guardian about hunger cues in their newborn. Which of the following manifestations should the nurse include as early indications of hunger in newborns? (Select all that apply.)

6 :
A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

7 :
A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

9 :
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

10 :
A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?

QLexNursing

2 : A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

3 : A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

4 : A nurse is reviewing the medical record of a client who is requesting an oral contraceptive for birth control. The nurse should identify which of the following findings as a contraindication for the use of oral contraceptives for this client?

5 : A nurse is teaching a new guardian about hunger cues in their newborn. Which of the following manifestations should the nurse include as early indications of hunger in newborns? (Select all that apply.)

6 : A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

7 : A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

8 : A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

9 : A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

10 : A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?

2 :
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

3 :
A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is reviewing the medical record of a client who is requesting an oral contraceptive for birth control. The nurse should identify which of the following findings as a contraindication for the use of oral contraceptives for this client?

5 :
A nurse is teaching a new guardian about hunger cues in their newborn. Which of the following manifestations should the nurse include as early indications of hunger in newborns? (Select all that apply.)

6 :
A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

7 :
A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

9 :
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

10 :
A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?