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 observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Offer to take the newborn to the nursery to finish his feeding
- B. Insist that the mother pick up the newborn to feed him
- C. Demonstrate how to hold the newborn and allow the client to practice
- D. Persuade the client to breastfeed the newborn to promote bonding
Correct Answer: C
Rationale: Demonstrating safe holding respects the client's concerns while promoting bonding, unlike nursery removal, insistence, or pushing breastfeeding.
A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?
- A. Turn the client onto their side
- B. Initiate an amnioinfusion for the client
- C. Administer naloxone to the client
- D. Monitor the client's blood pressure every 15 min
Correct Answer: A
Rationale: Turning the client to their side improves uterine blood flow, addressing epidural-induced hypotension, unlike amnioinfusion, naloxone (irrelevant), or monitoring alone.
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).
A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
- A. A newborn who has a short frenulum and is having difficulty breastfeeding
- B. A newborn who is 24 hr old and has not had a meconium stool
- C. A newborn who is 10 hr old and has blood-tinged discharge in her diaper
- D. A newborn who is 10 hr old and has new onset tachypnea
Correct Answer: D
Rationale: New onset tachypnea signals potential respiratory distress, requiring urgent assessment, unlike breastfeeding issues, delayed stool, or normal blood-tinged discharge.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
- A. Midline episiotomy
- B. Meconium-stained fluid
- C. Gestational hypertension
- D. Placenta previa
Correct Answer: B
Rationale: Meconium-stained fluid increases maternal infection risk if it enters the bloodstream, unlike episiotomy (managed risk), hypertension, or previa (other complications).