Nokea
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.
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A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring, the nurse should perform Leopold maneuvers to assess the fetal position, presentation, lie, and engagement. This helps in determining the optimal placement of the transducer for accurate monitoring of the fetal heart rate. It allows the nurse to locate the fetal back and position the transducer over the fetal heart for the best signal quality.
Choices A, C, and D are incorrect:
A: Determining progression of dilatation and effacement is not necessary before applying the external transducer.
C: Completing a sterile speculum exam is not needed for fetal monitoring.
D: Preparing a Nitrazine paper test is unrelated to applying an external transducer.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
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.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B. The client at 34 weeks with epigastric pain is the priority as it could indicate preeclampsia, a serious condition requiring immediate attention to prevent harm to both the mother and the baby. Epigastric pain can be a sign of liver involvement in preeclampsia. Gestational diabetes (choice A) with slightly elevated blood glucose levels can be managed and monitored. Low hemoglobin levels at 28 weeks (choice C) may require treatment but are not as urgent as potential preeclampsia. Urinary symptoms at 39 weeks (choice D) could be indicative of a urinary tract infection, which is important but not as urgent as suspected preeclampsia.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks of gestation, a positive contraction stress test indicates potential placental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, muscle tone, breathing, amniotic fluid volume, and heart rate reactivity. This test helps determine the need for immediate delivery.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood for genetic testing and not for assessing fetal well-being. Amnioinfusion (B) is used to increase amniotic fluid volume during labor and not for evaluating fetal well-being. Chorionic villus sampling (D) is an invasive prenatal diagnostic test for genetic abnormalities and not for assessing fetal well-being.