MUNICIPALIDAD DE SANTA BÁRBARA

28. The nurse is caring for a postpartum client who is a Jehovah’s Witness and needs a RhoGAM injection. Which question should the nurse ask the client?

1. “RhoGAM is a blood product. Do you want the injection?” 2. “Do you know what type blood your husband has?

3. “Did you know that you have Rh-negative blood?”

4. “Do you know whether your insurance will pay for the shot?”

29. The nurse is administering medications to clients on a postpartum floor. Which medication should the nurse question administering?

1. The rubella vaccine to the postpartum client who has a negative titer. 2. The yearly flu vaccine to a client who reports an allergy to eggs. 3. The PPD to a client who suspects she was exposed to tuberculosis. 4. The hepatitis B vaccine to a client who is breast-feeding.

30. Which client would the newborn nursery nurse assess first after receiving shift report?

1. The newborn who has chignon. 2. The newborn with caput succedaneum. 3. The newborn who has a cephalhematoma. 4. The newborn who has a port-wine stain.

PRACTICE QUESTIONS ANSWERS AND RATIONALES

Setting Priorities When Caring

for Clients

1. 1. This pain may be related to an episiotomy or perineal tear, but this client is not prior- ity over a client who may be hemorrhaging.

2. Saturating multiple peri-pads indicates heavy bleeding, which may indicate hemorrhaging. The nurse should assess this client first.

3. The nurse needs to assess this client for possible maternal/infant bonding problems, but this is a psychosocial issue that should be addressed after a physiologic issue, such as possible hemorrhaging.

4. This client is going to require some time to be taught, but this is not priority over a client who is hemorrhaging.

MAKING NURSING DECISIONS:The test taker should apply some systematic approach when answering a priority ques- tion. Maslow’s Hierarchy of Needs should be used when determining which client to assess first. The test taker should start at the bottom of the pyramid, and physiologic needs are priority.

2. 1. The newborn with lanugo is normal and would not warrant immediate intervention by the nurse.

2. The normal respiratory rate for a newborn is 30 to 60; therefore, this would not war- rant immediate intervention.

3. The newborn who is turning red when cry- ing is not in distress; therefore, this would not warrant immediate intervention.

4. The newborn who has not passed meco- nium 24 hours after birth must

be evaluated for intestinal obstruction or a congenital abnormality. This could be caused by an imperforate anus, Hirschsprung’s disease, cystic fibrosis, or several other possibilities. This new- born warrants immediate intervention.

MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situ- ation. After eliminating the expected options, the test taker should determine which situation is more life threatening.

3. 1. The nurse should first intervene to increase blood supply to the fetus; therefore, notify- ing the HCP is not the nurse’s first inter- vention.

2. Slow, deep breaths may help decrease the mother’s anxiety, but the nurse’s first inter- vention is to increase blood supply to the fetus.

3. The left lateral position will improve placental blood flow and oxygen supply to the fetus. This should be the nurse’s first intervention.

4. The nurse should prepare for an emergency C-section, but this is not the nurse’s first intervention.

MAKING NURSING DECISIONS:When the test taker is deciding when to notify an HCP, the test taker should look at the other three options and determine whether one of the options should be implemented prior to notifying the HCP. Another option may, for example, provide information the HCP will need in order to make a decision.

4. 1. Once the nurse definitely determines the infant is not in the nursery, then a Code Pink should be initiated. This notifies all hospital personnel of a possible infant abduction.

2. This will be done if the infant was not returned to the nursery, but this is not the first intervention.

3. The nurse should first determine whether another staff member returned the infant to the nursery. The nurse should not call a false alarm.

4. There are many safety precautions to pre- vent infant abductions, and most facilities have a code word that is changed daily. The mother must ask anyone who wants to take the infant out of the mother’s room for the code word. This is not the nurse’s first intervention.

5. 1. Pain for the mother is a priority, but it is not priority over potential death of the fetus.

2. The client is not having trouble breathing; therefore, this would not be a priority prob- lem. Altered gas exchange would be an appropriate problem for the fetus.

3. The client is exhibiting signs of abruptio placentae, and a decreased heart rate indi- cates a compromised fetus. This problem will lead quickly to death of the fetus. Therefore, it is the priority problem.

4. All pregnant women experience an increase in fluid volume status and some resulting electrolyte imbalance; therefore, this is not a priority problem.

6. 1. The client with severe lower abdominal cramping should be called to determine whether she is currently menstruating, but this is not priority over a pregnant client with symptoms of pre-eclampsia.

2. Blurred vision is a symptom of pre- eclampsia, and this is the client’s first pregnancy. This client should be con- tacted first and told to come into the clinic for further evaluation.

3. The expulsion of dark red blood clots indi- cates the client is going through

menopause. This is not a life-threatening situation because dark red blood does not indicate frank bleeding.

4. This is uncomfortable for the client and indicates the need for a hysterectomy or instructions in the insertion and use of a pessary device to hold the uterus in place, but it is not life threatening.

MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the expected options, the test taker should determine which situation is more life threatening.

7. 1. The white blood cell count rises normally during labor and post partum—up to 25,000; therefore, this does not warrant intervention. 2. The serum creatinine level is within normal

limits; therefore, this client does not war- rant immediate intervention.

3. Platelets show marked increase 3 to 5 days after birth, but the client who is 1 to 2 days post partum would have a slightly increased platelet count. Normal platelet count is 150,000 to 450,000, so this client’s count is within normal limits.

4. This glucose level is elevated, and the nurse should investigate further as to why the glucose level is abnormal. The normal glucose level is 70 to 120 mg/dL. 8. 1. The client with type 1 diabetes must

receive insulin prior to eating; therefore, this must be administered first.

2. The stool softener will take several days to soften the stool; therefore, this medication does not need to be administered first. 3. The client with a headache is not priority

over a type 1 diabetic patient who needs sliding scale coverage. This client should receive medication after the insulin- dependent diabetic receives insulin. 4. The rectal suppository is administered to

shrink the hemorrhoids and has a local anesthetic effect, but it would not be pri- ority over the sliding scale insulin.

9. 1. A prolapsed cord is an emergency sit- uation because the prolapsed cord could compromise the fetus’s blood supply. Placing the client in the Trendelenberg position will cause the fetus to reverse back into the uterus, which will take the pressure off the umbilical cord. The safety of fetus is priority.

2. In emergency situations, the nurse may need to request visitors to leave the deliv- ery room, depending on how visitors are acting during the crisis, but this is not the first intervention.

3. This is an appropriate intervention, but the nurse’s priority is getting pressure off the umbilical cord.

4. The fetus is in distress and the nurse must prepare for an emergency C-section, but it is not the nurse’s first intervention.

10. 1. The newborn who weighs 6 pounds and 2 ounces is within normal weight for a newborn; therefore, the nurse would not need to assess this baby first.

2. The newborn delivered at 42 weeks is postmature and is at risk for hypo- glycemia and hypothermia because the placenta begins to deteriorate after 40 weeks and subcutaneous fat is utilized to support the infant’s life. The nurse should assess this baby first just because of the 42-week gestation.

3. The newborn who is 22 inches long is longer than most infants, but this infant would not need to be assessed first. 4. The newborn delivered at 40 weeks

gestation is within normal gestation time; therefore, the nurse would not need to assess this baby first.

MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are