Nokea
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
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A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
- A. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
- B. Patient states that she is eating healthy and limiting intake of processed foods.
- C. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
- D. Patient has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night.
Correct Answer: A
Rationale: The correct answer is (A) because losing 30 lb in the 6-week postpartum period is concerning as it is excessive and may indicate underlying health issues like hyperthyroidism or inadequate nutrition. This rapid weight loss can also affect the mother's energy levels, milk production, and overall health.
Choice (B) is incorrect as eating healthy and limiting processed foods is a positive behavior that supports weight management. Choice (C) is also incorrect as increased consumption of fruits and vegetables is beneficial for overall health. Choice (D) is incorrect because resuming a light exercise routine like walking is generally encouraged postpartum, as long as it is done safely and does not lead to excessive strain.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
To determine cultural influences on a patient's diet, what is the nurse's primary action?
- A. Evaluate the patient's weight gain during pregnancy.
- B. Assess the socioeconomic status of the patient.
- C. Discuss the four food groups with the patient.
- D. Identify the food preferences and methods of food preparation common to the patient's culture.
Correct Answer: D
Rationale: The correct answer is D because identifying the food preferences and methods of food preparation common to the patient's culture is crucial in understanding cultural influences on their diet. This step helps the nurse tailor dietary recommendations that align with the patient's cultural background and preferences, promoting better adherence and health outcomes.
Option A is incorrect as weight gain during pregnancy is not directly related to cultural influences on diet. Option B, assessing socioeconomic status, is important but not the primary action for understanding cultural influences on diet. Option C, discussing the four food groups, is too generic and does not specifically address cultural influences on diet.
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
Which nursing intervention is an independent function of the professional nurse?
- A. Administering oral analgesics
- B. Requesting diagnostic studies
- C. Teaching the patient perineal care
- D. Providing wound care to a surgical incision
Correct Answer: C
Rationale: Teaching is an independent nursing function, whereas administering medications or requesting diagnostic studies are dependent functions requiring physician orders.