Nokea
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
- A. Difficulty in arousing
- B. Deep tendon reflexes 2+
- C. Urinary output of 30 mL per hour
- D. Respiratory rate of 10 breaths/minute
Correct Answer: B
Rationale: Deep tendon reflexes at 2+ indicate a therapeutic magnesium level, preventing seizures without toxicity. Difficulty arousing, low urinary output (below 40 mL/hr), or respiratory rate of 10 suggest toxicity, requiring intervention.
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A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through sexual contact.
- D. It is primarily transmitted through respiratory droplets.
Correct Answer: C
Rationale: HIV is primarily transmitted through sexual contact involving infected fluids like semen or vaginal secretions. Mosquitoes, respiratory droplets, and puncture wounds (rare) don't commonly spread HIV.
A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.
- A. Ultrasound visualization of the fetus
- B. Softening of the cervix
- C. Positive pregnancy test
- D. Absence of menstruation
- E. Ballottement
- F. Auscultation of a fetal heart beat
Correct Answer: B,C,D,E
Rationale: Probable signs include softening of the cervix (Goodell's), positive pregnancy test (hCG), amenorrhea, and ballottement (fetal rebound). Ultrasound and fetal heartbeat are positive signs, confirming pregnancy definitively.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through casual contact.
- D. It is primarily transmitted through direct contact with infected body fluids.
Correct Answer: D
Rationale: HIV spreads mainly through direct contact with infected fluids (blood, semen, vaginal fluid), like during sex or needle sharing. Mosquitoes, casual contact, and puncture wounds (rare) aren't primary modes.
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year-old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
- A. 3-2-1-0-3
- B. 4-1-1-1-3
- C. 4-2-1-3-1
- D. 3-1-2-2-3
Correct Answer: B
Rationale: GTPAL: Gravida (4 pregnancies: twins, son, abortion, current), Term (1 at 39 weeks), Preterm (1 at 34 weeks), Abortions (1 at 6 weeks), Living (3 children). Thus, 4-1-1-1-3 is correct. Other options miscalculate pregnancies, preterm births, or living children.
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?
- A. Marijuana
- B. Cocaine
- C. Nicotine
- D. Caffeine
Correct Answer: B
Rationale: Cocaine causes tachycardia, hypertension, and vasoconstriction, risking placental abruption and fetal distress. Marijuana causes relaxation, nicotine raises heart rate but vasodilates, and caffeine mildly stimulates but doesn't constrict vessels.