Nokea
The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.
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A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
A client at 39 weeks' gestation is in labor and reports intense back pain. What is the likely cause?
- A. Occiput posterior fetal position.
- B. Placental abruption.
- C. Breech presentation.
- D. Uterine rupture.
Correct Answer: A
Rationale: Intense back pain during labor is commonly associated with the occiput posterior fetal position.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.
The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth? Which suggestion by the nurse is most appropriate?
- A. Break suction by inserting finger into corner of the infant mouth
- B. Elicit the moro reflex
- C. A popping sound
- D. Slowly remove breast from baby's mouth when the infant's mouth
Correct Answer: A
Rationale: The most appropriate suggestion by the nurse is to break the suction by gently inserting a clean finger into the corner of the infant's mouth. This method will safely release the baby's latch without causing any discomfort or injury to the baby or the mother. It is important to break the suction before removing the breast to prevent any potential damage to the nipple and promote a smooth breastfeeding experience for both the mother and the baby. This technique is commonly recommended in breastfeeding education to ensure proper latch and prevent nipple trauma.