Nokea
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
- A. 3+ deep tendon reflexes and hyperreflexia.
- B. Periorbital edema, flashing lights, and aura.
- C. Epigastric pain in the third trimester.
- D. Recent decreased urinary output.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
- A. Nausea and vomiting.
- B. Risk for infection.
- C. Sleep deprivation.
- D. Fluid volume excess.
Correct Answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client.
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?
- A. Itching sensation under the cast.
- B. Swelling of fingers with brisk capillary refill.
- C. Numbness and inability to move fingers.
- D. Visible bruising above the cast.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
- A. 150 mL/hour
- B. 250 mL/hour
- C. 50 mL/hour
- D. 275 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. In this case, with 20 grams of magnesium sulfate in 500 mL of solution, there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. This calculation ensures the correct dose is delivered within the specified time frame.
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?
- A. 45
- B. 15 mL
- C. 4
- D. 13
Correct Answer: D
Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.
A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
- A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
- B. Use a nipple shield to help the baby latch on.
- C. Try a different breastfeeding position.
- D. Have another person help the mother with breastfeeding.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.