Nokea
A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.
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What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
The nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result folic acid deficiency?
- A. iron deficiency anemia
- B. Poor bone formation
- C. Macrosomia fetus
- D. Neural tube defect
Correct Answer: D
Rationale: Folic acid is essential for the development of the neural tube in the fetus. When a pregnant woman has a deficiency in folic acid, it can lead to neural tube defects in the fetus. Neural tube defects are serious birth defects that affect the brain, spine, or spinal cord of the baby. The most common types of neural tube defects include spina bifida and anencephaly. Therefore, it is crucial for women of childbearing age to ensure an adequate intake of folic acid to prevent such birth defects.
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.
The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.
What immediate action should a nurse take for a mother reporting a severe headache postpartum?
- A. Administer analgesics and monitor blood pressure
- B. Encourage the mother to rest
- C. Apply a cold compress to the mother's head
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: A severe headache postpartum can indicate preeclampsia or other serious conditions requiring immediate action.