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A client at 36 weeks' gestation with eclampsia begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for:
- A. Abruptio placentae.
- B. Transverse lie.
- C. Placenta accreta.
- D. Uterine atony.
Correct Answer: A
Rationale: Abruptio placentae is a complication associated with eclampsia.
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The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
- A. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
- B. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
- C. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
- D. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.
Correct Answer: C
Rationale: Severe preeclampsia requires immediate attention.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
The nurse observes a bottle-feeding multiparous client tilting the bottle so the nipple is partially filled with air. The nurse should:
- A. Instruct the client to tilt the bottle to fill the nipple with formula.
- B. Suggest switching to a different nipple size.
- C. Encourage burping the neonate more frequently.
- D. Document the observation as normal.
Correct Answer: A
Rationale: Tilting the bottle to fill the nipple prevents air swallowing, reducing the risk of gas and regurgitation.
A client asks about the side effects of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. Nausea and breast tenderness may occur.
- B. It causes permanent infertility.
- C. It requires surgical insertion.
- D. It guarantees regular periods.
Correct Answer: A
Rationale: Nausea and breast tenderness are possible side effects of the vaginal contraceptive ring, especially initially. It does not cause permanent infertility, require surgical insertion, or guarantee regular periods.
A nurse is discussing the benefits of the copper IUD with a client. Which of the following statements by the nurse is accurate?
- A. The copper IUD can reduce menstrual bleeding.
- B. The copper IUD is effective for up to 10 years.
- C. The copper IUD requires daily monitoring.
- D. The copper IUD prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It may increase menstrual bleeding, does not require daily monitoring, and does not prevent ovulation, working primarily by affecting sperm motility.