Nokea
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. Encourage the client to ambulate twice per day.
- D. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
Correct Answer: B
Rationale: Seizure precautions are necessary in preeclampsia due to the risk of eclampsia from uncontrolled blood pressure. Measures include bedrails padding and medication administration to reduce seizure occurrences.
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A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity.
- B. Moderate tremors of the extremities.
- C. Axillary temperature 36.1°C (96.9° F).
- D. Excessive sleeping.
Correct Answer: B
Rationale: Moderate tremors result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
A nurse is caring for a client. Which of the following interventions should the nurse perform?
- A. Inspect the perineum.
- B. Massage the fundus.
- C. Administer oxytocin.
- D. Assist the client to void.
Correct Answer: B
Rationale: Massaging the fundus stimulates uterine contractions, reducing uterine atony and preventing further hemorrhage. This is a first-line intervention for postpartum excessive bleeding.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
Drag words from the choices below to fill in each blank in the following sentence: The nurse should [option] as a potential complication.
- A. The nurse should plan to discuss with the client the risk for hypothyroidism.
- B. The nurse should include fallopian tube rupture as a potential complication.
- C. The nurse should explain hypovolemic shock as a life-threatening risk.
- D. The nurse should elaborate on the development of an invasive mole.
Correct Answer: B
Rationale: Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication?
- A. Heart disease.
- B. Cervical dilation of 2 cm.
- C. Gestational age of 34 weeks.
- D. Allergy to penicillin.
Correct Answer: A
Rationale: Terbutaline is contraindicated in heart disease because it can cause tachycardia and arrhythmias, worsening cardiac conditions. Cardiovascular side effects result from its beta-adrenergic agonist action.