A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . .

• A.Rh-immune globulin at the next visit"
• B.Rh-immune globulin within 3 days of delivery"
• C.Rubella vaccine at the next visit"
• D.Rubella vaccine after delivery on the day of discharge"

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Home-care instructions for the child following a cardiac catheterization should include:

• A.Notify the physician if a slight bruise develops around the insertion site.
• B.Use sponge bathing until stitches are removed.
• C.Give aspirin if the child complains of pain at the insertion site.
• D.Keep a clean, dry dressing on the insertion site for 2 days.

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During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.
This may be due to:

• A.Endometritis
• B.Fibroid tumor on the uterus
• C.Displacement due to bowel distention
• D.Urine retention or a distended bladder

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The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

• A.Pedal pulses 11 (weak)
• B.Twenty-four-hour intake 1000 mL/day for past 2 days
• C.Serum potassium 3.3
• D.Pulse rate 150 bpm

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A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:

• A.November 23rd
• B.December 26th
• C.September 14th
• D.December 9th

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