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A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 10/min
- B. Urine output of 30 mL/hr
- C. Deep tendon reflexes 2+
- D. Client reports feeling warm
Correct Answer: A
Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.
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A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?
- A. Instruct the client to perform rapid, shallow breathing
- B. Prepare the client for an emergency cesarean birth
- C. Have the client perform pelvic tilts during contractions
- D. Apply counterpressure to the client's sacrum
Correct Answer: A
Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.
A client in the first trimester of pregnancy who is experiencing nausea is receiving teaching from a nurse. Which of the following instructions should the nurse include in the teaching?
- A. Drink water with meals
- B. Consume small, frequent meals
- C. Eat high-fat foods
- D. Lie down after eating
Correct Answer: B
Rationale: The correct instruction for a client in the first trimester of pregnancy experiencing nausea is to consume small, frequent meals. This helps alleviate nausea by preventing an empty stomach and maintaining stable blood sugar levels. Drinking water with meals can sometimes exacerbate nausea, especially in the case of morning sickness. Eating high-fat foods can be heavy on the stomach and worsen nausea. Lying down after eating can lead to reflux and is not recommended, especially for pregnant individuals experiencing nausea.
A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?
- A. This medication will help prevent contractions.
- B. This medication will reduce my baby's risk of respiratory distress.
- C. This medication will prevent early labor.
- D. This medication will increase my baby's weight.
Correct Answer: B
Rationale: Correct answer: Option B. Betamethasone is a glucocorticoid used to promote fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Option A is incorrect because betamethasone does not prevent contractions. Option C is incorrect as betamethasone does not prevent early labor but helps improve fetal lung development. Option D is incorrect as betamethasone does not increase the baby's weight.
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should eat foods high in protein before bedtime.
- B. You should avoid consuming liquids with your meals.
- C. You should eat three large meals per day.
- D. You should consume caffeine to help with nausea.
Correct Answer: B
Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.
A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?
- A. Painless vaginal bleeding
- B. Severe abdominal pain
- C. Uterine contractions
- D. Increased fetal movement
Correct Answer: A
Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.