NCLEX quiz: Perinatal safety and administration

The nurse in obstetrical triage evaluates 4 clients. Which of the following should be attended to first?

Four-month postpartem single mother who states she is afraid of shaking her baby when he cries
Sixteen-week pregnant client with occasional sharp left pains that start at the symphysis and radiate to fundus
Thirty-two week pregnant client requesting assistance with locating a new physician
Ten-week pregnant client complaining of nausea, vomiting, fatigue, and urinary frequency

Several clients have had antenatal testing completed. Which results would prompt the nurse to notify the health care provider?

Primagravida reporting fetal movement 6 times in 2 hours
Primagravida, infant with biophysical profile of 9
Multigravida, infant has reactive non-stress test
Multigravida with positive oxytocin challenge

During teaching, the nurse instructs a primagravid client that folic supplements are recommended in order to prevent neural tube defects, as well as:

Prevent blood glucose fluctuations
Promote absorption of iron supplements
Prevent anemia in mothers
Promote blood clotting and collagen formation

A pregnant client calls her obstetric office and informs the nurse that she cannot afford the prescribed prenatal vitamins. The nurse should refer this client to:

The charge nurse
The social worker
The insurance company
The office finance accountant

Which of the following obstetric patients would be acceptable to assign to a licensed practical nurse (LPN)?

A G 2, P 1 client with history of hyperemesis gravidarum
A G 1, P 0 client leaking green anmiotic fluid
A G 3, P 1, Ab 1 client at 33 weeks gestation
A G 4, P 3 client with history of gestational diabetes

A client who received an epidural during delivery requests to use the restroom 45 minutes after delivery. In order to provide the safest care, the nurse should:

Inform the client that she will need staff assistance
Request the client remain in bed until routine 15-minute checks have been completed
Assess the client’s ability to stand and bear weight
Position the client sitting on the side of the bed for 5 minutes prior to ambulating

While addressing the needs of a client with postpartum hemorrhage, the health care provider verbally ordered Methergine 0.2 mg intramuscularly (IM), and the dose was administered by the nurse. During chart review, the nurse notes the order entered into the electronic medical record by the health care provider as Methergine 0.2 mg PO. The nurse should:

File an incident report
Do nothing, but chart the medication IM as given
Inform the charge nurse to get the health care provider to change the order
Call the health care provider to discuss the order, and request revision if verbal order was heard correctly

A client is unable to void 9 hours after delivery. As the nurse cleanses the meatus, the client asks, “Are you using Betadine?” The nurse realizes the client may be reacting to the cleansing agent. Which of the following should the nurse do first?

Ask the client what her normal reaction to Betadine is
Cleanse the Betadine from the meatus
Contact the ordering health care provider
Document an incident report

A nurse is walking down a corridor of the hospital when a Code Pink alarm sounds on the loudspeaker system. The nurse should first:

Guard the hospital’s front entrance to check persons leaving the hospital
Report to the obstetrics ward to offer assistance
Monitor people in the immediate vicinity carrying large bags or oversized coats
Return to her assigned unit to receive further instructions

The nurse on a mother-baby unit has the following tasks to complete from 5 am to 7 am. Which task should be completed SECOND?

Assess a newborn that just arrived on the unit
Draw blood for the ordered postpartum blood counts (CBCs) on three clients
Draw newborn bilirubin level at 6 am
Start intravenous line on postpartum client to run at keep vein open (KVO) rate