Nokea
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should:
- A. Maintain continuous fetal monitoring.
- B. Encourage family members to remain at bedside.
- C. Assess reflexes, clonus, visual disturbances, and headache.
- D. Monitor maternal liver studies every 4 hours.
Correct Answer: C
Rationale: Monitoring signs of CNS irritability such as reflexes, clonus, visual disturbances, and headache helps detect worsening preeclampsia.
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While caring for a neonate delivered at 32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist?
- A. The presence of $1 \mathrm{~mL}$ of gastric residual before a gavage feeding.
- B. Jaundice appearing on the face and chest.
- C. An increase in bowel peristalsis.
- D. Abdominal distention.
Correct Answer: D
Rationale: Abdominal distention is a key sign of NEC, indicating potential intestinal compromise.
A nurse is counseling a client about the fertility awareness method. Which of the following client statements indicates a need for further teaching?
- A. I will track my basal body temperature daily.
- B. I will monitor my cervical mucus for changes.
- C. I will avoid intercourse during my fertile days.
- D. I can rely on this method even with irregular cycles.
Correct Answer: D
Rationale: The fertility awareness method is less reliable with irregular cycles, as ovulation is harder to predict. The other statements reflect correct understanding, indicating a need for further teaching about cycle regularity.
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.
Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)?
- A. Neonates are commonly listless and lethargic.
- B. The IQ scores are usually average.
- C. Hyperactivity and speech disorders are common.
- D. The mortality rate is 70% unless treated.
Correct Answer: C
Rationale: Hyperactivity and speech disorders are common in FAS due to neurological and developmental impacts.
A client is considering the lactational amenorrhea method (LAM) for contraception. Which of the following conditions must be met for LAM to be effective?
- A. The client must be exclusively breastfeeding, amenorrheic, and less than 6 months postpartum.
- B. The client must be breastfeeding at least once daily and less than 12 months postpartum.
- C. The client must be amenorrheic and supplementing with formula.
- D. The client must be exclusively breastfeeding and have regular periods.
Correct Answer: A
Rationale: LAM is effective when the client is exclusively breastfeeding, amenorrheic, and less than 6 months postpartum, as these conditions suppress ovulation. The other options include factors that reduce its effectiveness, such as formula supplementation or regular periods.