Nokea
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
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What is the priority nursing action for a newborn with a temperature of 35.5°C (95.9°F)?
- A. Place the newborn under a radiant warmer
- B. Administer warm IV fluids
- C. Swaddle the newborn in warm blankets
- D. Provide glucose supplementation
Correct Answer: A
Rationale: Placing the newborn under a radiant warmer helps raise body temperature and prevent complications.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
Medication that are contraindicated for management of PPH include SATA (Cytotec, Hemabate, Pitocin, Methergine all for PPH)
- A. Terbutaline (for preterm labor)
- B. Magnesium sulfate
- C. Methergine
- D. Pitocin
Correct Answer: A
Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.
The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.