Nokea
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
- A. Decrease in frequency of contractions
- B. BP 150/100 mm Hg
- C. Absent deep tendon reflexes
- D. Urinary output 35 mL/hr
Correct Answer: C
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, a serious complication requiring immediate reporting to prevent further harm, unlike reduced contractions (desired effect), elevated BP (monitor but less urgent), or low-normal urine output.
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A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Abdominal distention
- B. Third-degree perineal laceration
- C. Vaginal candidiasis
- D. Afterpain
Correct Answer: B
Rationale: A third-degree perineal laceration contraindicates suppositories to avoid further trauma and delayed healing, unlike distention, candidiasis, or afterpain, which are not contraindications.
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will return to the clinic in 8 weeks for my next injection
- B. I will get two shots each time I receive this medication
- C. I should increase my calcium intake while taking this medication
- D. I should discontinue this medication if I experience spotting
Correct Answer: C
Rationale: Increased calcium intake mitigates bone density loss from medroxyprogesterone, unlike incorrect 8-week injections (12 weeks), multiple shots, or stopping for spotting (normal).
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
- A. Three fetal movements perceived by the client in a 20 min testing period
- B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
- C. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period
- D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
Correct Answer: A
Rationale: Only three fetal movements in 20 minutes is below the expected activity level, suggesting possible fetal compromise, unlike reassuring heart rate responses or minor contractions.
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
- A. The client has a fundal height of 38 cm
- B. The client has a fasting blood glucose of 90 mg/dL
- C. The client reports 12 fetal movements in 1 hr
- D. The client has nonpitting pedal edema
Correct Answer: A
Rationale: A fundal height of 38 cm at 32 weeks suggests macrosomia, a gestational diabetes complication, requiring reporting, unlike normal glucose, fetal movements, or edema.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Monitor the rectal temperature every 4 hr
- B. Administer broad-spectrum antibiotics
- C. Cleanse the site with povidone-iodine
- D. Prepare for surgical closure after 72 hr
Correct Answer: B
Rationale: Broad-spectrum antibiotics prevent meningitis from CSF leakage, unlike rectal temperature (contraindicated), povidone-iodine (neurotoxic), or delayed surgery (urgent within 24-48 hours).