• The nurse is planning care for a client at 30-weeks gestation who is experiencing
preterm labor.
• Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3
• Ampicillin 1 gram IV push q8h.
• Betamethasone (Celestone) 12 mg deep IM
• Butorphanol (Stadol) 1 mg IV push q2h PRN pain
2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl
and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her
diet?
• Carrots
• Chicken
• Yogurt
• Cheese
3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a
postpartum client. Based on what assessment finding should the nurse withhold the drug?
• Respiratory rate of 22 breaths/min
• A large amount of lochia rubra
• Blood pressure 149/90
• Positive Homan’s sign
, 4. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis
(JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding
muscle. Which physical therapy regimen should the nurse encourage the adolescent to
implement?
• Begin a training program lifting weights and running
• Splint affected joints during activity
• Exercise in a swimming pool
• Perform passive range of motion exercises twice daily
5. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most
important for the nurse to obtain each time the infusion rate is increased?
• Pain level
• Blood pressure
• Infusion site
• Contraction pattern
6. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell
count is 15.000/mm. What action should the nurse take first?
• Check the differential, since the WBC is normal for this client
• Assess the client’s temperature, pulse, and respirations q4h
• Assess the client’s perineal area for signs of a perineal hematoma
• Notify the healthcare provider, since this finding is indicative of infection
7. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous
genitalia. What is the primary nursing consideration when supporting the parents of a child
with this anomaly?
, • Discuss the need for cortisol and aldosterone replacement therapy after discharge
• Support the parents in their decision to assign sex of their child according to their
preference
• Offer information about ultrasonography and genotyping to determine sex
assignment
• Explain that corrective surgical procedures consistent with sex assignment can be
delayed
8. The nurse assessing a 9-year old boy who has been admitted to the hospital with
possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what
information is most significant?
• Back pain for a few days
• A history of hypertension
• A sore throats last week
• Diuresis during the nights
Note: Page 1538 MB
9. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm
labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the
nurse administer?
13
10. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart
rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action
should the nurse implement first?
• Alert the neonatal team and prepare for neonatal resuscitation
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