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NurseDive Free Nursing Practice Question

The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

A. Measure vital signs.

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

B. Obtain human chorionic gonadotropin levels.

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

C. Collect urine sample for urinalysis.

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

D. Recommend bed rest.

Recommending bed rest is not the most appropriate action based on the given symptoms.

This question is an excerpt from Nurse Dive's nursing test bank - Care Hope College RN HESI Maternity Proctored Exam. Take the full exam now


Full Explanation

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.


Similar Questions

QUESTION

A healthcare provider prescribes a maintenance dose of 2 grams per hour of intravenous magnesium sulfate for a client with preeclampsia.

The IV bag contains 20 grams of magnesium sulfate in 500 mL of 5% dextrose in water.

How many mL/hour should the nurse set the infusion pump to deliver? (Note: This is a medical math, so no options are provided.)

Full Explanation

To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.

Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL

Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.

We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.

QUESTION

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia.

The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

Full Explanation

Step 1:

4 grams ÷ 20 grams × 500 mL = 100 mL

Step 2:

100 mL ÷ 20 minutes × 60 minutes/hour = 300 mL/hour

Answer:

300 mL/hour

QUESTION

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer’s 1 liter.

How many mL/hour should the nurse program the infusion pump to deliver? .

Full Explanation

The correct answer is calculated as follows:

Step 1: Identify the total amount of oxytocin in the IV bag. The bag contains 20 units of oxytocin in 1 liter (or 1000 mL) of lactated Ringer’s solution.

Step 2: Convert the oxytocin units to milliunits. 1 unit = 1000 milliunits, so 20 units = 20,000 milliunits.

Step 3: Calculate the concentration of the oxytocin solution in milliunits/mL. Divide the total amount of oxytocin in milliunits by the total volume of the solution in mL.

So, 20,000 milliunits ÷ 1000 mL = 20 milliunits/mL.

Step 4: Calculate the infusion rate in mL/hour. The prescription is for an infusion rate of 2 milliunits/min. Since the concentration of the solution is 20 milliunits/mL, we divide the prescribed rate by the concentration to get the rate in mL/min. So, 2 milliunits/min ÷ 20 milliunits/mL = 0.1 mL/min.

Step 5: Convert the infusion rate to mL/hour. Multiply the rate in mL/min by the number of minutes in an hour. So, 0.1 mL/min × 60 min/hour = 6 mL/hour. Therefore, the nurse should program the infusion pump to deliver 6 mL/hour.