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A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Monitor blood pressure pulse, and respirations every 4 hour
- B. Keep an airway at the bedside
- C. Allow liberal family visitation
- D. Assess temperature every hour
Correct Answer: B
Rationale: Eclampsia can lead to seizures, making airway management equipment critical to ensure safety during a potential seizure event.
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The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
- A. Discuss options for intrauterine surgical correction of congenital defects.
- B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
- C. Reassure the client that the AFP results are likely to be a false reading.
- D. Explain that a sonogram should be scheduled for definitive results
Correct Answer: D
Rationale: An elevated AFP level is a screening indicator, not a diagnosis. A sonogram is the next step to assess for neural tube defects or other anomalies, providing definitive information.
The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens
- B. Explain common complications of pregnancy
- C. Obtain baseline blood pressure and weight
- D. Schedule prenatal visits to occur monthly
Correct Answer: A
Rationale: Given the history of syphilis, obtaining blood and urine for prenatal screens is critical to assess for active infection or other risks that could impact the pregnancy.
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
- A. Hemoglobin and hematocrit
- B. Abdominal contour and bowel sounds
- C. Heart rate and blood pressure
- D. Urinary output and IV fluid intake
Correct Answer: C
Rationale: A perineal hematoma can cause significant pain and pressure, potentially leading to hemodynamic instability. Assessing heart rate and blood pressure first is crucial to detect signs of shock or circulatory compromise.