Nokea
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs.
- B. Swelling of feet and ankles at the end of the day.
- C. Headache that is unrelieved by analgesia.
- D. Braxton Hicks contractions.
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a potentially serious condition such as preeclampsia, which requires immediate medical attention to prevent complications for the mother and baby. Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is expected in pregnancy due to increased fluid retention. Braxton Hicks contractions (D) are normal and not a cause for concern unless they become regular and closer together.
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A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can cause toxicity leading to respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the muscles. Having it readily available ensures prompt treatment in case of toxicity.
Restricting fluid intake (A) is not necessary for preeclampsia and can lead to dehydration. Assessing deep tendon reflexes (C) every 6 hours is important but not as crucial as having the antidote readily available. Monitoring intake and output (D) every 4 hours is important for overall assessment but does not directly address magnesium sulfate toxicity.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
- E. Anxiety Disorder
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. Cholecystitis is a contraindication due to the risk of gallbladder disease. Hypertension is a contraindication because estrogen in oral contraceptives can exacerbate hypertension. Migraine headaches are a contraindication due to the increased risk of stroke. Human papillomavirus and anxiety disorder are not contraindications for oral contraceptives.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we look at the assessment findings. For "Greenish discharge," this is consistent with both trichomoniasis and gonorrhea. Trichomoniasis typically presents with a frothy, yellow-green discharge, while gonorrhea can cause a greenish or yellow discharge. "Pain on urination" is also a common symptom of both gonorrhea and trichomoniasis. Therefore, the correct answer is B, D. Abdominal pain is not specific to any of the mentioned conditions and is not a defining symptom. Diabetes is not directly related to the assessment findings provided. The absence of a condom is not a symptom but rather a risk factor for sexually transmitted infections.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. The nurse will carry your baby in their arms to the nursery for scheduled procedures.
- B. We will document the relationship of visitors in your medical record.
- C. It is okay for your baby to sleep in the bed with you while in the hospital.
- D. Staff members who take care of your baby will be wearing a photo identification badge.
Correct Answer: D
Rationale: The correct answer is D: Staff members who take care of your baby will be wearing a photo identification badge. This statement promotes the security and safety of the newborn by ensuring that only authorized personnel are handling the baby. It helps prevent unauthorized individuals from gaining access to the newborn. This practice aligns with hospital security protocols and minimizes the risk of infant abduction or mix-ups.
Choice A is incorrect as it goes against current safety practices of not carrying newborns to the nursery by non-parents for security reasons. Choice B is unrelated to the security and safety of the newborn. Choice C is incorrect as it goes against safe sleep guidelines which recommend placing the baby in a separate sleep area to reduce the risk of Sudden Infant Death Syndrome (SIDS).
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) and monitoring the FHR (D) are important but not the priority immediately post-procedure. Observing for uterine contractions (B) is important but not the priority for an Rh-negative client after amniocentesis.