Nokea
A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
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The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?
- A. Oliguria
- B. Hypersomnolence
- C. Hyporeflexia
- D. Bradypnea
Correct Answer: C
Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.
A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.
- A. Desire for adoption planning services
- B. Emotional response to the pregnancy
- C. Family/social support systems
- D. Nutritional habits and substance use
- E. Plan for finishing high school
Correct Answer: A,B,C,D,E
Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?
- A. Blood glucose of 450 mg/dL
- B. Potassium level of 4.0 mEq/L
- C. PaO2 of 92 mmHg
- D. HCT of 60
Correct Answer: C
Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.