Nokea
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.
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For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it could indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. It requires medical intervention to prevent complications.
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are common in pregnancy due to increased blood volume and hormonal changes. They are usually not a significant concern unless they are severe or accompanied by other symptoms.
D: Increased vaginal discharge is a normal occurrence in pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically a cause for immediate concern unless it is accompanied by other symptoms like itching, burning, or foul odor.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from the cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. This is the priority because an unresponsive client may be experiencing respiratory distress, which can quickly lead to hypoxia and cardiac arrest. Assessing respiratory function allows the nurse to intervene promptly if needed. Increasing IV fluid rate (B) is important but not the first priority. Accessing emergency medications (C) may be necessary, but addressing respiratory status comes first. Collecting a blood sample for coagulopathy studies (D) is important for assessing bleeding disorders but is not the immediate priority in this situation.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B because epigastric pain in a pregnant client at 34 weeks of gestation could indicate a serious condition such as preeclampsia. Preeclampsia is a potentially life-threatening condition characterized by high blood pressure and organ damage. It requires immediate assessment and intervention to prevent complications for both the mother and the baby. The other clients have less urgent issues that can be managed with ongoing monitoring and interventions. A: Gestational diabetes with a slightly elevated blood glucose level can be managed with adjustments to diet and medication. C: Mildly low hemoglobin levels can be addressed with iron supplementation and monitoring. D: Urinary frequency and dysuria in a client at 39 weeks of gestation are common symptoms of late-stage pregnancy and do not indicate a critical issue.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours of unprotected sex. Taking it as soon as possible maximizes its effectiveness in preventing pregnancy by delaying or inhibiting ovulation. Choice B is incorrect as levonorgestrel can be used even if the person is on an oral contraceptive. Choice C is incorrect because a delayed period does not necessarily indicate pregnancy; a pregnancy test should be taken if there are other signs of pregnancy. Choice D is incorrect because levonorgestrel is only effective for a short period after taking it and does not provide long-term protection against pregnancy.