Nokea
A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?
- A. Ask the client's mother to call an ambulance for transport to the hospital immediately.
- B. Determine what physical activities the client has performed for the past 24 hours.
- C. Teach the client how to perform pelvic rock exercises and observe for correct feedback.
- D. Ask the client if she has experienced any recent changes in vaginal discharge.
Correct Answer: D
Rationale: The priority nursing intervention in this situation is to ask the client if she has experienced any recent changes in vaginal discharge. Changes in vaginal discharge can indicate preterm labor, making it crucial to assess promptly. This information will help determine if the client needs immediate medical attention and appropriate interventions to prevent preterm birth and ensure the well-being of the mother and the baby. Option A is not the priority as back pain alone does not warrant immediate ambulance transport. Option B is less relevant in this context as the focus should be on immediate concerns related to pregnancy. Option C is not the priority as addressing back pain should come after ruling out urgent pregnancy-related issues.
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Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
- C. I know you're upset. Would you like to talk about some activities you could do while in bed?
- D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.
Correct Answer: A
Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.
The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client?
- A. Clonidine hydrochloride
- B. Carbamazepine
- C. Furosemide
- D. Magnesium sulfate
Correct Answer: D
Rationale: In the scenario presented, the client is exhibiting signs and symptoms of severe preeclampsia, including hypertension, proteinuria, facial and hand swelling, visual disturbances, and a severe headache. The medication of choice for preventing seizures in preeclampsia is magnesium sulfate. This drug helps to prevent and control seizures in clients with preeclampsia, making it the most appropriate option for this client. Clonidine hydrochloride (Choice A) is an antihypertensive medication used for managing hypertension but is not the first-line treatment for preeclampsia. Carbamazepine (Choice B) is an anticonvulsant used for seizure disorders like epilepsy and is not indicated for preeclampsia. Furosemide (Choice C) is a diuretic used to manage fluid retention but is not the drug of choice for treating preeclampsia.
A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?
- A. CO2 combining power
- B. Calcium
- C. Sodium
- D. Chloride
Correct Answer: B
Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.
A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?
- A. Obtain a culture of any sputum or wound drainage
- B. Initiate normal saline IV at 50 ml/hr
- C. Administer a loading dose of penicillin IM
- D. Administer the initial dose of folic acid PO
Correct Answer: B
Rationale: In a child with a sickle cell crisis, the priority intervention is to initiate normal saline IV at 50 ml/hr to manage dehydration and help alleviate pain. This intervention helps improve hydration status and supports the circulation of sickled red blood cells, reducing the risk of vaso-occlusive episodes and associated pain. Obtaining a culture of any sputum or wound drainage (Choice A) may be necessary but is not the initial priority. Administering a loading dose of penicillin IM (Choice C) is important but not the first intervention. Administering the initial dose of folic acid PO (Choice D) is beneficial but does not address the immediate need for hydration in a sickle cell crisis.
During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
- A. lower Apgar scores.
- B. lower birth weights.
- C. respiratory distress.
- D. a higher rate of congenital anomalies.
Correct Answer: B
Rationale: When mothers smoke during pregnancy, it is associated with intrauterine growth restriction, which leads to lower birth weights in infants. Maternal smoking can restrict the flow of oxygen and nutrients to the fetus, affecting its growth and development. This can result in babies being born with lower birth weights, which can have various health implications for the newborn. Choices A, C, and D are incorrect as smoking during pregnancy is primarily linked to intrauterine growth restriction and lower birth weights in infants, rather than lower Apgar scores, respiratory distress, or a higher rate of congenital anomalies.