Nokea
A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
- A. Epidural analgesia
- B. Naloxone hydrochloride
- C. Attention-focusing
- D. Pudendal nerve block
Correct Answer: C
Rationale: The correct answer is C: Attention-focusing. At 40 weeks gestation with a platelet count of 75,000/mm3, epidural analgesia is contraindicated due to the risk of epidural hematoma. Naloxone hydrochloride is an opioid antagonist used for opioid overdose, not for labor pain relief. Pudendal nerve block is used for local anesthesia during the second stage of labor, not for early labor pain relief. Attention-focusing techniques can help the client manage pain without pharmacological interventions, ensuring safety for both the client and the baby.
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A healthcare professional is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the healthcare professional anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine
- B. Pyridoxine
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. When magnesium sulfate toxicity is suspected, calcium gluconate is administered because it antagonizes the effects of magnesium on the heart and central nervous system. This helps to counteract the muscle weakness, respiratory depression, and cardiac arrhythmias associated with magnesium toxicity. Nifedipine (A) is a calcium channel blocker and is not indicated for magnesium toxicity. Pyridoxine (B) is a form of vitamin B6 and is not used to treat magnesium toxicity. Ferrous sulfate (C) is an iron supplement and is not relevant in the management of magnesium toxicity.
A healthcare provider is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the healthcare provider include when discussing true labor?
- A. Contractions become stronger with walking.
- B. Discomfort can be relieved with a back massage.
- C. Contractions become irregular with a change in activity.
- D. Discomfort is felt above the umbilicus.
Correct Answer: A
Rationale: The correct answer is A: Contractions become stronger with walking. This is because true labor is characterized by contractions that consistently increase in intensity and frequency, which is often enhanced by physical activity like walking. Contractions in false labor do not typically intensify with movement. Discomfort in true labor is usually not easily relieved by a back massage (B) and contractions in true labor remain regular even with changes in activity (C). Discomfort in true labor is typically felt in the lower abdomen and back, not above the umbilicus (D).
A healthcare professional is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the healthcare professional include? (Select all that apply)
- A. Avoid any lifting
- B. Perform Kegel exercises twice a day
- C. Perform the pelvic rock exercise every day
- D. Avoid standing for prolonged periods
Correct Answer: C
Rationale: The correct answer is C: Perform the pelvic rock exercise every day. This exercise helps strengthen the core muscles, which can alleviate backache during pregnancy. It also promotes flexibility in the lower back and pelvis.
Avoiding any lifting (A) is not a practical measure as some lifting may be necessary in daily activities. Performing Kegel exercises (B) strengthens pelvic floor muscles but does not directly address backache. Avoiding standing for prolonged periods (D) can help reduce backache but is not as effective as specific exercises targeting the back muscles like the pelvic rock exercise.
A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)
- A. Respirations less than 12/min
- B. Urinary output less than 25 mL/hr
- C. Decreased level of consciousness
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Magnesium sulfate toxicity can lead to respiratory depression (respirations less than 12/min), decreased urinary output (less than 25 mL/hr), and altered mental status (decreased level of consciousness). Respiratory depression occurs due to the impact of magnesium on the central nervous system. Decreased urinary output is a result of magnesium's effects on renal blood flow. Altered mental status is a common sign of magnesium toxicity affecting brain function. Reporting these signs promptly is crucial to prevent serious complications. The other choices (A, B, C) are incorrect because they are all potential signs of magnesium sulfate toxicity and should be reported.
A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?
- A. Bruising over the buttocks
- B. Hard nodules on the roof of the mouth
- C. Petechiae over the head
- D. Bilateral periauricular papillomas
Correct Answer: C
Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.