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A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?
- A. Monitor for contractions
- B. Assess pain level
- C. Assess for hemorrhage
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Assess for hemorrhage. This is the priority assessment as the client is experiencing painful bleeding, indicating a potential hemorrhage which can be life-threatening. Assessing for hemorrhage will help identify the severity of the situation and guide immediate interventions. Monitoring for contractions (choice A) is important but assessing for hemorrhage takes precedence. Assessing pain level (choice B) is important but addressing the potential hemorrhage is more critical. Providing emotional support (choice D) is important but should come after addressing the urgent medical need of assessing for hemorrhage.
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The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?
- A. Assessing lung sounds
- B. Assessing blood sugar level
- C. Encouraging fluid intake
- D. Assessing for pitting edema
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate can cause respiratory depression, necessitating close monitoring of lung sounds to detect any signs of respiratory distress. Assessing lung sounds is crucial for early detection and intervention. Blood sugar level (B) monitoring is not directly related to magnesium sulfate therapy. Encouraging fluid intake (C) may be important, but not as critical as assessing lung sounds. Assessing for pitting edema (D) is important for overall assessment but not the highest priority in this scenario.
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
- A. Position the client supine with the head of the bed elevated 30 degrees.
- B. Get baseline blood pressure and pulse and monitor frequently during administration.
- C. Administer medication every 5 minutes until blood pressure is stabilized.
- D. Inform the client that this may cause a positive direct Coombs test result.
Correct Answer: B
Rationale: The correct answer is B. Getting baseline blood pressure and pulse and monitoring frequently during administration is crucial because hydralazine is a potent antihypertensive medication that can cause significant drops in blood pressure. Monitoring allows for early detection of hypotension or adverse reactions.
A is incorrect because positioning the client supine with the head of the bed elevated 30 degrees is not specific to the administration of hydralazine for pre-eclampsia.
C is incorrect because administering medication every 5 minutes until blood pressure is stabilized is not a standard protocol for hydralazine administration; it should be given as per physician's orders with appropriate monitoring.
D is incorrect because informing the client about a positive direct Coombs test result is not relevant to the administration of hydralazine; this is more pertinent to medications that can cause hemolytic anemia.
A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage.
Incorrect choices:
B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia.
C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia.
D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening condition.
During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect may indicate pulmonary edema. This condition occurs due to fluid accumulation in the lungs, leading to symptoms like coughing. The increased blood volume and pressure during pregnancy can exacerbate the client's existing heart condition, resulting in pulmonary edema. Orthopnea (choice A) is difficulty breathing when lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not typically associated with a nonproductive cough. Decreased blood volume (choice D) would not directly lead to a nonproductive cough on minimal exertion.
The nurse is assessing a client who has been diagnosed with gestational diabetes. Which should the nurse monitor closely because of her diagnosis?
- A. Edema
- B. Blood pressure, pulse, and respiration
- C. Urine for glucose and ketones
- D. Hemoglobin and hematocrit
Correct Answer: C
Rationale: The correct answer is C: Urine for glucose and ketones. In gestational diabetes, monitoring urine for glucose and ketones is crucial to assess blood sugar control and ketosis. Glucose in urine indicates hyperglycemia, and ketones indicate inadequate insulin and potential ketoacidosis. Monitoring edema (choice A) is not specific to gestational diabetes. Blood pressure, pulse, and respiration (choice B) are important but not specific to gestational diabetes. Monitoring hemoglobin and hematocrit (choice D) does not directly reflect blood sugar control in gestational diabetes.