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A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
- A. Evaluate fetal heart rate and contraction patterns.
- B. Obtain prescription to repeat hepatic panel.
- C. Monitor for evidence of seizure activity.
- D. Check the urinary output in hourly urinometer.
- E. Inspect the perineum for vaginal bleeding.
Correct Answer: A,B,C,D
Rationale: Monitoring fetal heart rate, repeating hepatic panel, checking for seizures, and assessing urinary output address potential HELLP syndrome and renal function in preeclampsia.
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A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from Neisseria gonorrhoeae, protecting the newborn's eyes from infection.
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
Which action should the nurse take?
- A. Document the normal finding.
- B. Notify the healthcare provider.
- C. Schedule an ultrasound.
- D. Obtain hematocrit level.
Correct Answer: B
Rationale: Notifying the healthcare provider about abnormal FHR patterns ensures timely intervention to address potential fetal distress.