Nokea
A client is being treated with eclampsia. What is a priority nursing intervention?
- A. Assess for hyperreflexia
- B. Administer oxygen
- C. Monitor blood pressure every 15 minutes
- D. Prepare for delivery
Correct Answer: A
Rationale: Eclampsia is a serious complication of pregnancy characterized by seizures. Hyperreflexia is often a precursor to eclampsia, and assessing for it can help predict and manage the condition before seizures occur.
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A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest thrusts
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct Answer: C
Rationale: If routine suctioning with a bulb syringe is ineffective, the next step is to use mechanical suction. This ensures that any obstruction in the airway is cleared. If the newborn's condition does not improve, chest compressions or further interventions may be needed.
A nurse is providing care to a client with severe preeclampsia. Which of the following medications should the nurse anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct Answer: A
Rationale: Magnesium sulfate is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention.
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?
- A. Encourage the mother to breastfeed the newborn
- B. Gavage feed 60 mL (2 oz) of glucose water
- C. Administer 10 mL of D5W via IV
- D. Recheck the glucose level in 2 hr
Correct Answer: A
Rationale: Encouraging the mother to breastfeed is appropriate, as breastfeeding can quickly raise blood glucose levels in newborns. A level of 45 mg/dL is often acceptable but should be monitored closely.
A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.