Nokea
A client at 30 weeks' gestation is receiving corticosteroids. What is the primary purpose of this therapy?
- A. To prevent preterm labor.
- B. To enhance fetal lung maturity.
- C. To reduce maternal blood pressure.
- D. To lower blood glucose levels.
Correct Answer: B
Rationale: The correct answer is B: To enhance fetal lung maturity. Corticosteroids given to a client at 30 weeks' gestation help accelerate fetal lung maturation, reducing the risk of respiratory distress syndrome in the newborn. This therapy does not prevent preterm labor but rather prepares the baby's lungs for potential early delivery. It also does not directly impact maternal blood pressure or blood glucose levels. Therefore, the primary purpose of corticosteroid therapy in this scenario is to benefit the baby's lung development, making option B the correct choice.
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The primigravida is admitted to the birthing and labor unit, but
- A. The initial response from the nurse will be to:
- B. Take health history
- C. Perform vaginal exam
- D. Review prenatal record
Correct Answer: B
Rationale: The correct answer is B: Take health history. This is the initial response because obtaining the patient's health history provides crucial information about the primigravida's medical background, current health status, any complications, and helps in assessing the risk factors for labor and delivery. This information guides the nurse in providing appropriate care and making informed decisions during the labor process.
Choice A (The initial response from the nurse will be to) is vague and not specific enough to address the immediate needs of the patient.
Choice C (Perform vaginal exam) is not appropriate as the first action because it can be invasive and should only be performed after obtaining the health history to determine the necessity and timing of the exam.
Choice D (Review prenatal record) is important but should come after taking the health history to supplement the information obtained and provide a comprehensive understanding of the patient's pregnancy course.
People in extended families can live together for many reasons. What can the nurse do to provide the best care for a person living with an extended family?
- A. Assume the family is poor and needs information on financial assistance.
- B. Ask the person if they would like the family members to remain in the room during the exam.
- C. Set a limit on who is allowed in the room with the person regardless of the circumstances.
- D. Address the family first then the patient.
Correct Answer: B
Rationale: The correct answer is B because it respects the person's autonomy and preferences by asking if they want family members present during the exam. This approach ensures the person's comfort and privacy while also promoting family involvement in care. Choice A assumes financial need without evidence. Choice C limits family support. Choice D may neglect the person's immediate needs.
A nurse is caring for a client who is receiving Iv magnesium sulfate which of the following medication should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine (Adalat)
- B. Pyridoxine (vitamin B)
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. In cases of magnesium sulfate toxicity, calcium gluconate is administered as an antidote due to its ability to counteract the effects of magnesium. Magnesium and calcium ions have an antagonistic relationship in the body, so administering calcium gluconate can help reverse the toxic effects of magnesium. Nifedipine (A), Pyridoxine (B), and Ferrous sulfate (C) do not have a direct antidote effect on magnesium toxicity and are not indicated for this purpose.
Placental circulation is dependent on maternal circu- tions for preventing sudden infant death syndrome? lation. In which maternal circumstances is placental Select all that apply. circulation impeded? Select all that apply.
- A. Position newborns in the prone position to
- B. Hypotension
- C. Pre-eclampsia
- D. Avoid soft bedding or pillows in the newborn's
Correct Answer: B
Rationale: The correct answer is B: Hypotension. Hypotension in the mother can result in decreased blood flow to the placenta, affecting placental circulation and oxygen delivery to the fetus, increasing the risk of sudden infant death syndrome.
A: Positioning newborns in the prone position does not directly impede placental circulation.
C: Pre-eclampsia can affect placental circulation due to high blood pressure, but it is not the only maternal condition that can impede placental circulation.
D: Avoiding soft bedding or pillows in the newborn's crib is related to safe sleep practices but does not directly impede placental circulation.
A client at 39 weeks' gestation reports sudden gush of fluid. What is the nurse's priority action?
- A. Perform a sterile vaginal exam.
- B. Assess fetal heart rate.
- C. Check maternal vital signs.
- D. Administer IV fluids.
Correct Answer: B
Rationale: The correct answer is B: Assess fetal heart rate. The priority action in this situation is to assess the well-being of the fetus since the client reported a sudden gush of fluid, which could indicate rupture of membranes. Assessing the fetal heart rate helps determine if the fetus is experiencing distress. Performing a sterile vaginal exam (A) can introduce infection and is not the priority. Checking maternal vital signs (C) can be done after assessing the fetal well-being. Administering IV fluids (D) is not the priority until the fetal status is determined.