Nokea
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers.
- B. Absence of clonus.
- C. Leg cramps.
- D. Blurred vision.
Correct Answer: D
Rationale: Blurred vision may result from severe preeclampsia or elevated blood pressure, signifying potential end-organ damage. It requires immediate medical evaluation to prevent progression to eclampsia.
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For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity.
- B. Excessive high-pitched cry.
- C. Acrocyanosis.
- D. Respiratory rate of 50/min.
Correct Answer: B
Rationale: Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate's difficulty in self-regulation.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 minutes.
- B. Contraction duration of 100 seconds.
- C. Fetal heart rate of 118/min.
- D. Fetal heart rate with moderate variability.
Correct Answer: B
Rationale: Contraction duration of 100 seconds exceeds the normal range (usually less than 90 seconds), risking uterine hyperstimulation and fetal compromise, necessitating oxytocin discontinuation.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: Rear-facing car seats support a baby's head and spine during sudden stops or collisions. Experts recommend maintaining this position until 2 years to reduce injury risk.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.