Nokea
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. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia.
Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated.
Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension.
Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.
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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 for hyperglycemia and ketosis, which can indicate poor blood sugar control. This helps in adjusting the treatment plan and preventing complications.
A: Edema is not directly related to gestational diabetes and is more commonly associated with conditions like heart failure or kidney disease.
B: Monitoring blood pressure, pulse, and respiration is important in general health assessment but not specific to gestational diabetes.
D: Hemoglobin and hematocrit levels are important for monitoring anemia, but not directly related to gestational diabetes management.
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is a recommended treatment for cervical incompetency to prevent preterm birth. Progesterone helps support the uterine lining and decrease the risk of preterm labor. Therefore, discussing the action and side effects of progesterone with the patient is essential.
A: While an abdominal ultrasound may provide information about the cervix, it is not the immediate priority in this case.
B: Placing the patient on her left side is a common practice for improving blood flow, but it is not directly related to managing cervical incompetency.
D: Monitoring blood pressure is important in prenatal care, but it is not specifically related to the management of cervical incompetency in this context.
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are at higher risk for hyperemesis gravidarum due to hormonal changes and inadequate nutritional intake. Adolescents often experience rapid growth and increased nutritional demands, leading to a higher susceptibility to conditions like hyperemesis gravidarum. High levels of hCG (A) are common in pregnancy and can contribute to nausea and vomiting but are not the primary cause of hyperemesis gravidarum. High blood pressure (B) is not directly related to hyperemesis gravidarum. Being underweight (D) may exacerbate the condition but is not the primary factor causing hyperemesis gravidarum in this case.
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn.
Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn.
Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission.
Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.
Which factor places the client at the highest risk of pre-eclampsia?
- A. White race
- B. Multiparity
- C. Obesity
- D. Infertility
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a significant risk factor for pre-eclampsia due to the increased strain on the cardiovascular system and potential inflammatory effects. It can lead to hypertension and vascular dysfunction, contributing to the development of pre-eclampsia. White race (A) is not a specific risk factor for pre-eclampsia. Multiparity (B) is a risk factor, but obesity has a higher association with pre-eclampsia. Infertility (D) is not a known risk factor for pre-eclampsia. In summary, obesity poses the highest risk due to its direct impact on cardiovascular health and inflammation.