Nokea
The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
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Which of the following is an example of healthy grieving?
- A. The mother exhibits an absence of crying or expression of feelings.
- B. The parents do not mention the baby in conversation with family members.
- C. The mother asks that the baby be taken away from the delivery area quickly.
- D. While holding the baby, the mother says to her husband, "He has your eyes and nose."
Correct Answer: D
Rationale: Option D, while holding the baby, the mother saying to her husband, "He has your eyes and nose," is an example of healthy grieving. In this scenario, the mother is acknowledging the baby, expressing emotions, and involving her partner in the process. Verbalizing thoughts and emotions, as well as creating meaningful connections with relevant support persons, are important aspects of healthy grieving. Sharing memories and recognizing the physical similarities between the baby and family members can be therapeutic in the grieving process.
Which data must the nurse consider before administering Depo-Provera (medroxyprogesterone acetate) to a postpartum client?
- A. The capsule must be taken at the same time each day.
- B. The client must be taught to use sunscreen whenever in the sunlight.
- C. The medicine is contraindicated if the woman has lung or esophageal cancer.
- D. The client must use an alternate form of birth control for the first two months.
Correct Answer: C
Rationale: Medroxyprogesterone acetate is contraindicated in women with certain cancers.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Tocolytic therapy is a medication given to delay preterm labor and prolong the pregnancy. It is safe and appropriate to administer tocolytic therapy to a client who is experiencing preterm labor at 26 weeks of gestation (option B) to help delay delivery and give time for other interventions to be initiated, such as administration of corticosteroids for fetal lung maturation and transfer to a facility with a NICU if necessary. The goal is to prevent premature birth and its associated complications.
The nurse should anticipate the labor pattern for a fetal occiput posterior position to be
- A. Prolonged and more painful
- B. Precipitous
- C. Rapid during transition
- D. Shorter than average during the latent phase
Correct Answer: A
Rationale: The nurse should anticipate the labor pattern for a fetal occiput posterior position to be prolonged and more painful. This is because in occiput posterior position, the baby's head is facing the mother's abdomen instead of her back, which can lead to slower descent and dilation of the cervix. The baby's head may have difficulty rotating to the optimal position for birth, causing longer labor and increased back pain for the mother. Nurses should be prepared to provide additional support and pain management strategies for women experiencing labor with a fetal occiput posterior position.
The best indication that correct attachment to the breast has occurred is when the:
- A. Baby's tongue is securely on top of the nipple.
- B. Baby's mouth covers most of the areolar surface
- C. Baby makes frequent loud clucking sounds while nursing at each breast d, Baby sucks each breast vigorously for five minutes before falling asleep
Correct Answer: B
Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.