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. 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.
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The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
A 35-year-old patient comes to the clinic 2 days after a tubal ligation. She complains of abdominal pain and swelling and redness at the surgical incision. What does the nurse know is a common complication of this procedure?
- A. Ileus
- B. Liver enlargement
- C. Constipation
- D. Infection
Correct Answer: D
Rationale: Infection is a common complication after tubal ligation, indicated by redness and swelling at the surgical site. Choice A is incorrect as ileus is a bowel obstruction, not typically a complication of tubal ligation. Choice B, liver enlargement, is unrelated to tubal ligation. Choice C, constipation, may be a side effect but is not a primary concern after this procedure.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
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.
The nurse is teaching a client about signs of preterm labor. Which symptom should be reported immediately?
- A. Increased fetal movements.
- B. Lower back pain and cramping.
- C. Mild swelling of the feet.
- D. Occasional Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.