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A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.
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A nurse is providing care to a client with severe preeclampsia. Which of the following medications should the nurse anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct Answer: A
Rationale: Magnesium sulfate is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention.
A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: The client should check for the string each month after menstruation to ensure the IUD is in place. Regular checks can help identify any displacement.
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby along with any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: The client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction, highlighting the importance of strict identification protocols in the hospital setting.
A postpartum client's fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take?
- A. Massage the fundus
- B. Administer oxytocin
- C. Assist the client to void then reassess the fundus
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Displacement of the uterus from the midline is often a sign of bladder distention. A full bladder can prevent the uterus from contracting properly, which could increase the risk of postpartum hemorrhage. The nurse should assist the client to void and then reassess the position and firmness of the fundus to ensure appropriate uterine contraction.