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A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
- A. Nausea and vomiting.
- B. Risk for infection.
- C. Sleep deprivation.
- D. Fluid volume excess.
Correct Answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client.
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The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
- A. Palpate the client's bladder.
- B. Check the pH of the vaginal fluid.
- C. Review the fetal heart rate pattern.
- D. Determine cervical dilation.
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
A child with ADHD needs help with homework. What should the nurse encourage the parents to do?
- A. Encourage the parents to help the child with homework.
- B. Do the homework for the child.
- C. Set a regular homework schedule.
- D. Provide a quiet environment for homework.
Correct Answer: A
Rationale: Encouraging parents to help the child with homework is beneficial as it fosters independence and academic skills. This involvement allows the child to receive the necessary support and guidance while still actively participating in their academic responsibilities, promoting a sense of accomplishment and skill development.
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.
The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
- A. Provide a quiet environment with subdued lighting.
- B. Have calcium gluconate immediately available.
- C. Assess deep tendon reflexes (DTRs) every 4 hours.
- D. Insert a Foley catheter with a urimeter to monitor hourly output.
Correct Answer: B
Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects.
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.