Nokea
A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. Her mother is at the bedside. The client's blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure?
- A. Decreased contraction intensity.
- B. Decreased temperature.
- C. Epigastric pain.
- D. Hyporeflexia.
Correct Answer: C
Rationale: Epigastric pain is a warning sign of impending eclampsia.
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A multigravid client in active labor at term suddenly sits up and says, 'I can't breathe! My chest hurts really bad!' The client's skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next?
- A. Administer oxygen by face mask.
- B. Begin cardiopulmonary resuscitation.
- C. Administer intravenous oxytocin.
- D. Obtain an order for intravenous fibrinogen.
Correct Answer: A
Rationale: Sudden dyspnea, chest pain, and dusky skin suggest a possible pulmonary embolism or amniotic fluid embolism. Administering oxygen improves oxygenation while awaiting further intervention. CPR is premature, oxytocin is irrelevant, and fibrinogen is for coagulopathy.
A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure. The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FiO₂) of 0.23. The pulse oximetry reading is 70% saturation. In which order of priority from first to last should the nurse take these actions?
- A. Increase the $\mathrm{FiO}_2$.
- B. Make sure the pulse oximeter is correlating to the heart rate.
- C. Assess the neonate for color.
- D. Assess the neonate for respiratory effort.
Correct Answer: B,C,D,A
Rationale: First, ensure the pulse oximeter is accurate (B). Then, assess clinical signs like color (C) and respiratory effort (D). Finally, adjust $\mathrm{FiO}_2$ (A) if needed based on findings.
A 24-year-old client is discussing contraception options with the nurse and expresses interest in an intrauterine device (IUD). Which of the following statements by the client indicates a need for further teaching?
- A. I understand the IUD can remain in place for several years.
- B. The IUD will prevent ovulation each month.
- C. I may experience heavier menstrual periods with the copper IUD.
- D. The IUD does not protect against sexually transmitted infections.
Correct Answer: B
Rationale: The IUD does not primarily prevent ovulation; it works by affecting sperm movement and preventing fertilization (copper IUD) or thinning the uterine lining (hormonal IUD). The other statements are correct, indicating a need for further teaching about its mechanism.
While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?
- A. I should try to gently manually replace the hemorrhoid.
- B. Analgesic sprays and witch hazel pads can relieve the pain.
- C. I should lie on my back as much as possible to relieve the pain.
- D. I should drink lots of water and eat foods that have a lot of roughage.
Correct Answer: C
Rationale: Lying on the back increases pressure on hemorrhoids, worsening discomfort; the other statements reflect correct measures.
A client asks the nurse about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods likeå®çŸ³
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.