Nokea
A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Establish the frequency of headaches.
- B. Ask about a history of delivering large babies.
- C. Examine the client for pedal edema.
- D. Collect a urine sample to screen for protein.
Correct Answer: D
Rationale: Severe headache and hypertension suggest preeclampsia. Screening for proteinuria is critical to confirm the diagnosis and guide urgent management.
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A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood cultures.
- B. Administer penicillin.
- C. Prepare for a cesarean section.
- D. Cover the lesion with a dressing.
Correct Answer: C
Rationale: Cesarean section prevents neonatal herpes transmission during delivery with active lesions.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for client with preterm labor. The IV bag contains 'Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.' How many mL/hour should the nurse set the infusion pump?
- A. 450 mL/hour
Correct Answer: A
Rationale: For 6 grams in 20 minutes, 150 mL (6 ÷ 0.04 g/mL) is needed. Infusion rate is 150 mL ÷ 20 min × 60 = 450 mL/hour.
The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?
- A. Return of the uterus to prepregnancy size.
- B. Expulsion of the placenta.
- C. Activation of the let down reflex.
- D. Stimulation of uterine contractions.
Correct Answer: D
Rationale: Oxytocin stimulates uterine contractions to reduce postpartum bleeding by compressing blood vessels.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.