A nurse is reviewing the laboratory results for a client who has a BP of
156/102 mm Hg and is at 36 weeks of gestation. Which of the following
laboratory values should the nurse report to the provider? - ANS ✓Platelet
count 100,000/mm
The nurse should identify that a platelet count of 100,000/mm is below the
expected reference range of 150,000 to 400,000/mm during pregnancy. A
low platelet count can indicate HELLP syndrome; therefore, the nurse
should report this laboratory value to the provider.
A nurse is caring for a client who is 1 hr postpartum and has a third-degree
perineal laceration. Which of the following actions should the nurse
perform? (Select all that apply.) - ANS ✓Apply an ice pack to the client's
perineum is correct. The nurse should apply an ice pack to the client's perineum
to decrease edema and promote comfort.
Place witch hazel pads on the client's perineum is correct. The nurse should
place witch hazel pads on the client's perineum to promote comfort.
Encourage the client to use a squeeze bottle to cleanse the perineum with
each void is correct. The nurse should encourage the client to use a squeeze
bottle to cleanse the perineum with each void to prevent infection.
A nurse is assisting with the admission assessment of a client whose labor
is being induced. The client reports using heroin 6 hr ago. For which of the
following manifestations of abstinence should the nurse monitor the client?
- ANS ✓Insomnia
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Abstinence manifestations begin within 6 hr after the last drug use and
might include insomnia, shivering, body aches, vomiting, nausea, body
shivers, abdominal pain, muscle jerks, and diarrhea.
A nurse is reinforcing teaching with the parents of a newborn who is having
a newborn screening test. Which of the following statements should the
nurse include in the teaching? - ANS ✓The test will check your baby for
phenylketonuria."
The nurse should reinforce with the parents that the newborn screening
test checks for multiple congenital disorders including sickle cell disease.
phenylketonuria, galactosemia, and hypothyroidism. Most of these
disorders are not symptomatic at birth.
A nurse is assisting with discharge teaching about pain management to a
client who had a cesarean birth and is experiencing gas pains. Which of the
following instructions should the nurse include in the teaching? - ANS
✓Rock in a rocking chair.
The nurse should instruct the client that rocking in a rocking chair can help
to relieve gas pains by aiding the client in expelling the gas.
A nurse is reinforcing teaching about an amniocentesis with a client who is
at 36 weeks of gestation. Which of the following statements by the client
indicates an understanding of the teaching? - ANS ✓"The procedure will
determine if my baby's lungs are mature."
The provider performs an amniocentesis late in the pregnancy to
determine fetal lung maturity. The amniotic fluid will be evaluated for the
lecithin/sphingomyelin ratio. A ratio of at least 2:1 indicates fetal lung
maturity.
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