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A client, who is in the second trimester of pregnancy, gestation. The client is receiving magnesium sulfate tells the nurse that she has developed a reddish-pink intravenously for pre-eclampsia. Which assessment skin color on the palm of her hands. Which of the fol- requires immediate intervention?
- A. Blood pressure of 130/90 mm Hg
- B. Urine output of 20 mL in past hour
- C. Facial flushing
- D. Patellar reflexes 2+
Correct Answer: C
Rationale: Facial flushing in a pregnant client receiving magnesium sulfate for pre-eclampsia can be a sign of magnesium toxicity. Magnesium sulfate is a tocolytic agent used to prevent seizures in pre-eclamptic patients; however, excessive levels of magnesium can cause symptoms such as flushing, lethargy, blurred vision, slurred speech, and muscle weakness. In severe cases, magnesium toxicity can progress to respiratory depression, cardiac arrest, and death. Therefore, immediate intervention is required to prevent further complications. The other options do not present immediate concerning signs related to magnesium toxicity.
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A nurse educator is teaching a class to nursing developing cervical cancer. Which client is at students about the incidence of sexually transmitted highest risk? infections (STIs) and their impact on public health.
- A. Client with a Pap test and an HPV screen positive Which is the most commonly reported STI in the for type 12 United States?
- B. Client who is 40 years old and stopped smoking
- C. Syphilis
- D. Gonorrhea
Correct Answer: A
Rationale: Human papillomavirus (HPV) is the most commonly reported sexually transmitted infection (STI) in the United States. HPV infection, especially high-risk types such as HPV-16, is strongly associated with cervical cancer. Therefore, a client who is positive for HPV type 16 on an HPV screen is at the highest risk for developing cervical cancer among the given choices. The nurse educator would need to emphasize the importance of regular screening, follow-up, and prevention strategies for this client to reduce the risk of cervical cancer development.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's rate of breathing.
Correct Answer: B
Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.
A client comes to the labor and delivery with polyhydramnios. She was admitted and her membrane ruptures is clear and odorless, but the fetal heart monitor indicate bradycardia and variable decelerations. What should action should be taken next?
- A. Perform vaginal exam (lot of fluid, check to see where baby is)
- B. High fowler position
- C. Warm saline soak vaginal
- D. Perform Leopold maneuver
Correct Answer: A
Rationale: In this scenario, with the presence of polyhydramnios and clear, odorless amniotic fluid, the fetal heart monitor indicating bradycardia and variable decelerations indicates a potential umbilical cord compression due to excessive amniotic fluid volume. It is crucial to perform a vaginal exam promptly as this can help assess the position of the baby and determine if there is a cord prolapse or any other complications that may be affecting the fetal heart rate. The baby's position needs to be identified quickly to address potential issues and ensure a safe delivery process.
Which of the following best describes the mechanism of action of birth control pills?
- A. They block sperm from reaching the egg.
- B. They prevent ovulation by suppressing hormone levels.
- C. They increase cervical mucus production to block sperm entry.
- D. They reduce the size of the ovaries and fallopian tubes to prevent pregnancy.
Correct Answer: B
Rationale: Birth control pills primarily work by preventing ovulation, thereby inhibiting the release of eggs for fertilization. Choice A is incorrect because birth control pills do not directly block sperm; they prevent ovulation. Choice C is partially correct but is not the main mechanism, as the primary function is to prevent ovulation. Choice D is incorrect because birth control pills do not alter the size of reproductive organs.