A 4-week-old premature infant has been C
receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
indicates to the nurse that the drug is resulting in an increase in RBCs. Since the body has not had to compensate for
effective? anemia with an increased heart rate, changes in heart rate from high to normal is one
indicator that Epogen is effective.
Slowly increasing urinary output over the
last week.
Respiratory rate changes from the 40s to
the 60s.
Changes in apical heart rate from the 180s
to the 140s.
Change in indirect bilirubin from 12 mg/dl to
8 mg/dl.
A 24-hour-old newborn has a pink papular C
rash with vesicles superimposed on the
thorax, back, and abdomen. What action Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly
should the nurse implement? referred to as "flea bites," but is a normal finding that is documented in the infant's
record, and requires no further action.
Notify the healthcare provider.
Move the newborn to an isolation nursery.
Document the finding in the infant's record.
Obtain a culture of the vesicles.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a
dose of terbutaline sulfate (Brethine) 0.25
mg subcutaneous . Which assessment is the
highest priority for the nurse to monitor
during the administration of this drug?
,A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a Monitoring maternal and fetal heart rates is most important when terbutaline is being
dose of terbutaline sulfate (Brethine) 0.25 administered becauseTerbutaline acts as a sympathomimetic agent that stimulates
mg subcutaneous . Which assessment is the both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2
highest priority for the nurse to monitor receptors (causing uterine relaxation, a desired effect of the drug).
during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a Monitoring maternal and fetal heart rates is most important when terbutaline is being
dose of terbutaline sulfate (Brethine) 0.25 administered becauseTerbutaline acts as a sympathomimetic agent that stimulates
mg subcutaneous . Which assessment is the both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2
highest priority for the nurse to monitor receptors (causing uterine relaxation, a desired effect of the drug).
during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on
an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for
the nurse to monitor during the
administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
,A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on
an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for
the nurse to monitor during the
administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 38-week primigravida who works as a C
secretary and sits at a computer 8 hours
each day tells the nurse that her feet have
begun to swell. Which instruction would be
most effective in preventing pooling of
blood in the lower extremities?
Wear support stockings.
Reduce salt in her diet.
Move about every hour.
Avoid constrictive clothing.
A 40-week gestation primigravida client is D
being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in
her lower back. Which intervention should
the nurse implement?
Discontinue the oxytocin (Pitocin) infusion.
Place the client in a semi-Fowler's position.
Inform the healthcare provider.
Apply firm pressure to sacral area.
, A 40-week gestation primigravida client is D
being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in
her lower back. Which intervention should
the nurse implement?
Discontinue the oxytocin (Pitocin) infusion.
Place the client in a semi-Fowler's position.
Inform the healthcare provider.
Apply firm pressure to sacral area.
A client at 28-weeks gestation arrives at the C
labor and delivery unit with a complaint of
bright red, painless vaginal bleeding. For Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an
which diagnostic procedure should the indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B
nurse prepare the client? and D) are invasive procedures that increase the risk for premature onset of labor, and
are not indicated at this client's gestation.
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithin-sphingomyelin ratio.
receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
indicates to the nurse that the drug is resulting in an increase in RBCs. Since the body has not had to compensate for
effective? anemia with an increased heart rate, changes in heart rate from high to normal is one
indicator that Epogen is effective.
Slowly increasing urinary output over the
last week.
Respiratory rate changes from the 40s to
the 60s.
Changes in apical heart rate from the 180s
to the 140s.
Change in indirect bilirubin from 12 mg/dl to
8 mg/dl.
A 24-hour-old newborn has a pink papular C
rash with vesicles superimposed on the
thorax, back, and abdomen. What action Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly
should the nurse implement? referred to as "flea bites," but is a normal finding that is documented in the infant's
record, and requires no further action.
Notify the healthcare provider.
Move the newborn to an isolation nursery.
Document the finding in the infant's record.
Obtain a culture of the vesicles.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a
dose of terbutaline sulfate (Brethine) 0.25
mg subcutaneous . Which assessment is the
highest priority for the nurse to monitor
during the administration of this drug?
,A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a Monitoring maternal and fetal heart rates is most important when terbutaline is being
dose of terbutaline sulfate (Brethine) 0.25 administered becauseTerbutaline acts as a sympathomimetic agent that stimulates
mg subcutaneous . Which assessment is the both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2
highest priority for the nurse to monitor receptors (causing uterine relaxation, a desired effect of the drug).
during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a Monitoring maternal and fetal heart rates is most important when terbutaline is being
dose of terbutaline sulfate (Brethine) 0.25 administered becauseTerbutaline acts as a sympathomimetic agent that stimulates
mg subcutaneous . Which assessment is the both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2
highest priority for the nurse to monitor receptors (causing uterine relaxation, a desired effect of the drug).
during the administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on
an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for
the nurse to monitor during the
administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
,A 30-year-old gravida 2, para 1 client is B
admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on
an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for
the nurse to monitor during the
administration of this drug?
Maternal blood pressure and respirations.
Maternal and fetal heart rates.
Hourly urinary output.
Deep tendon reflexes.
A 38-week primigravida who works as a C
secretary and sits at a computer 8 hours
each day tells the nurse that her feet have
begun to swell. Which instruction would be
most effective in preventing pooling of
blood in the lower extremities?
Wear support stockings.
Reduce salt in her diet.
Move about every hour.
Avoid constrictive clothing.
A 40-week gestation primigravida client is D
being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in
her lower back. Which intervention should
the nurse implement?
Discontinue the oxytocin (Pitocin) infusion.
Place the client in a semi-Fowler's position.
Inform the healthcare provider.
Apply firm pressure to sacral area.
, A 40-week gestation primigravida client is D
being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in
her lower back. Which intervention should
the nurse implement?
Discontinue the oxytocin (Pitocin) infusion.
Place the client in a semi-Fowler's position.
Inform the healthcare provider.
Apply firm pressure to sacral area.
A client at 28-weeks gestation arrives at the C
labor and delivery unit with a complaint of
bright red, painless vaginal bleeding. For Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an
which diagnostic procedure should the indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B
nurse prepare the client? and D) are invasive procedures that increase the risk for premature onset of labor, and
are not indicated at this client's gestation.
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithin-sphingomyelin ratio.
