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.
You may also like to solve these questions
A person is admitted to the antepartum floor for hypertension. The person is Hispanic and speaks fluent English. They tell the nurse they have been seeing a curandero, or traditional healer, for the past several years. What is the best initial response from the nurse?
- A. Ask the patient for a list of all herbs, plants, and special diets they are currently taking.
- B. Educate the person on why adherence to a Western medical treatment plan is better for their health.
- C. Inform the person that the treatment they have been receiving from the curandero is not evidence based.
- D. Tell the person that they are not considering the health of their baby by using these traditions.
Correct Answer: A
Rationale: Understanding the patient's use of traditional healing practices ensures safe integration with Western medicine.
The nurse is educating a G1P0 client who is 34 weeks in the third trimester. gestation and in her third trimester. Which of the
- A. I should gain 3.5 to 5 pounds in the first following educational topics would be appropriate trimester and 1 pound per week in the last two at this time? Select all that apply. trimesters.
- B. Contraception options after delivery
- C. I should gain 10 pounds in the first trimester,
- D. Group B strep (GBS) screen before onset of labor 10 pounds in the second trimester, and 10 pounds
Correct Answer: A
Rationale: I should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters.
A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)
- A. Elevate the head of the bed to at least 30°.
- B. Apply restraints if the client becomes agitated.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30° helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.
The nurse is monitoring a client with premature rupture of membranes at 37 weeks. Which prescription should the nurse question?
- A. Monitor fetal heart rate continuously.
- B. Monitor maternal vital signs frequently.
- C. Perform a vaginal examination every shift.
- D. Administer an antibiotic as prescribed.
Correct Answer: C
Rationale: Vaginal exams are minimized to reduce the risk of infection in clients with premature rupture of membranes.
On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.