Nokea
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
- A. 3+ deep tendon reflexes and hyperreflexia.
- B. Periorbital edema, flashing lights, and aura.
- C. Epigastric pain in the third trimester.
- D. Recent decreased urinary output.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences a return to red bleeding after transitioning to pink and white, it may indicate possible complications like hemorrhage or retained placental fragments. Instructing the client to reduce activity level and promptly notify the healthcare provider is crucial for timely evaluation and management of these potentially serious postpartum complications.
When should the LPN/LVN encourage the laboring client to begin pushing?
- A. When there is only an anterior or posterior lip of cervix left.
- B. When the client describes the need to have a bowel movement.
- C. When the cervix is completely dilated.
- D. When the cervix is completely effaced.
Correct Answer: C
Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
- A. Place the infant in a knee-chest position.
- B. Administer morphine sulfate.
- C. Start intravenous fluids.
- D. Provide 100% oxygen by face mask.
Correct Answer: A
Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?
- A. Slowly increasing urinary output over the last week.
- B. Respiratory rate changes from the 40s to the 60s.
- C. Changes in apical heart rate from the 180s to the 140s.
- D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
Correct Answer: C
Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective.
At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?
- A. Color and consistency of fluid.
- B. Estimated amount of fluid.
- C. Any odor noted at the rupture of membranes.
- D. Time of membrane rupture.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.