Nokea
A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
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A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care after birth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:
- A. Demonstrate appropriate coping mechanisms needed to get through the surgery.
- B. Accept that the type of delivery will not affect the bonding with the baby.
- C. Verbalize understanding about the reason for the unplanned surgery.
- D. Demonstrate decreased anxiety and fear of the unknown.
Correct Answer: C
Rationale: The correct answer is C: Verbalize understanding about the reason for the unplanned surgery. This outcome focuses on the client understanding why the cesarean delivery is necessary, which is crucial for informed decision-making and reducing anxiety. It shows the client comprehends the situation, which is important for her emotional well-being and cooperation during the procedure and postpartum period. Option A is incorrect because coping mechanisms are important but not directly related to knowledge deficit correction. Option B is incorrect as it does not address the client's knowledge deficit but rather focuses on emotional aspects. Option D is incorrect as it addresses anxiety and fear but not the underlying issue of knowledge deficit.
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
- A. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups.
- B. Recommend genetic counseling for parents,male siblings and paternal uncles and their male offspring.
- C. Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
- D. Have the child use an incentive spirometer and perform breathing exercises routinely.
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.
A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching?
- A. I can use a hair dryer on the reddened skin to help with the drying.
- B. I can use powder after diaper changes to absorb excess moisture.
- C. I can use cloth diapers with rubber outer pants until the rash clears.
- D. I can keep the diaper off to expose the skin to air.
Correct Answer: D
Rationale: Exposing the skin to air helps prevent irritation and promotes healing.
A nurse is reinforcing teaching about accidental poisoning to a parent during a routine well-child visit.
- A. "I will give my child a dose of ipecac."'
- B. "I will place my child on her back."'
- C. "I will call the Poison Control Center."'
- D. "I will get my child to drink a full glass of water."'
Correct Answer: C
Rationale: The correct answer is C: "I will call the Poison Control Center." This is the best course of action in case of accidental poisoning as they provide expert advice on managing poison exposure. Calling them ensures prompt and accurate guidance to prevent further harm. Option A (ipecac) is not recommended anymore as it can cause more harm. Option B (placing the child on her back) is irrelevant to poisoning treatment. Option D (full glass of water) is not recommended as it can dilute the poison and may worsen the situation.