Nokea
A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 reflexes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will first include:
- A. Administration of glucocorticoids(Betamethasone).
- B. Vaginal or cesarean delivery of the fetus.
- C. Prevention of seizures with phenytoin (Dilantin).
- D. Reduction of fluid retention with thiazides.
Correct Answer: B
Rationale: Delivery is the definitive treatment for severe preeclampsia.
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A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation?
- A. 1% lidocaine (Xylocaine).
- B. Naloxone hydrochloride (Narcan).
- C. Local anesthetic.
- D. Pudendal block.
Correct Answer: B
Rationale: In a client with recent opioid use, naloxone (Narcan) could precipitate withdrawal symptoms, which is risky during delivery. Lidocaine, local anesthetics, or pudendal blocks are safe for perineal anesthesia and do not interact with the client's history.
The physician orders oxytocin to be added to the intravenous fluids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following?
- A. First placenta.
- B. First twin.
- C. Second placenta.
- D. Second twin.
Correct Answer: C
Rationale: Oxytocin is administered post-delivery of both twins and placentas to promote uterine contraction and prevent postpartum hemorrhage. Administering earlier risks complications with the second twin or placentas.
A nurse is discussing sterilization with a female client. Which of the following statements by the client indicates a need for further teaching?
- A. Tubal ligation involves blocking my fallopian tubes.
- B. Tubal ligation is considered permanent.
- C. Tubal ligation will cause early menopause.
- D. Tubal ligation can be done laparoscopically.
Correct Answer: C
Rationale: Tubal ligation does not cause early menopause, as it only blocks the fallopian tubes and does not affect ovarian hormone production. The other statements are correct, indicating a need for further teaching.
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant? Select all that apply.
- A. Removing a Foley catheter from a preeclamptic client.
- B. Assisting an active labor client with breathing and relaxation.
- C. Ambulating a postcesarean client to the bathroom.
- D. Calculating hourly I.V. totals for a preterm labor client.
- E. Intake and output catheterization for culture and sensitivity.
- F. Calling a report of normal findings to the health care provider.
- G. Removing lunch trays and documenting lunch intake.
Correct Answer: C,G
Rationale: Delegating ambulation and lunch tray removal is appropriate for a nursing assistant.
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.