Nokea
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
- A. Temperature
- B. Fetal heart rate (FHR)
- C. Bowel sounds
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate (FHR). When administering magnesium sulfate for preterm labor, monitoring the fetal heart rate is crucial as magnesium sulfate can affect the fetal heart rate. It is important to assess for any signs of fetal distress promptly.
A: Temperature is important to monitor for signs of magnesium toxicity, but not the priority assessment in this situation.
C: Bowel sounds are not directly related to the administration of magnesium sulfate for preterm labor.
D: Respiratory rate is important to monitor for respiratory depression from magnesium sulfate, but assessing the fetal heart rate takes precedence in this scenario.
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Which of the following conditions is concerning to The nurse recognizes which as a risk factor for placenta the infant nursery nurse? abruptio? Select all that apply.
- A. An infant who passes a thick, greenish to black
- B. Use of alcohol stool with each bowel movement
- C. Hypertension
- D. Hard, small, white papules on the face of the
Correct Answer: C
Rationale: Correct Answer: C - Hypertension
Rationale:
1. Hypertension is a known risk factor for placental abruption.
2. Hypertension can lead to poor placental perfusion, increasing the risk of abruption.
3. Proper monitoring and management of hypertension are crucial to prevent adverse outcomes.
Summary:
A, B, D are unrelated to placental abruption and not risk factors. Hypertension is directly linked to placental abruption due to its impact on placental perfusion.
What is disordered eating?
- A. an occasional overeating episode
- B. a normal variation in eating patterns
- C. a range of abnormal eating behaviors and attitudes
- D. a preference for specific types of foods
Correct Answer: C
Rationale: The correct answer is C because disordered eating refers to a range of abnormal eating behaviors and attitudes that may indicate a potential eating disorder. This includes behaviors such as restrictive dieting, binge eating, purging, or obsessively controlling food intake. Option A is incorrect because an occasional overeating episode does not necessarily indicate disordered eating. Option B is incorrect as disordered eating is not considered a normal variation in eating patterns. Option D is incorrect as having a preference for specific types of foods does not classify as disordered eating unless it leads to serious negative consequences.
Which is a priority nursing intervention for a post-operative patient who has had an incomplete abortion?
- A. Insertion of IV line and fluid replacement
- B. Methergine IM (Clerie said this one to diminish bleeding, but Quizlet said bolded answer)
- C. Positioning client on left side
- D. Preop teaching for surgery
Correct Answer: A
Rationale: The correct answer is A: Insertion of IV line and fluid replacement. This is the priority nursing intervention for a post-operative patient with an incomplete abortion because fluid replacement is essential to address potential hypovolemia from bleeding. Ensuring adequate IV access allows for prompt administration of fluids and medications to stabilize the patient's condition. Choice B, Methergine IM, may help reduce bleeding but is not the immediate priority. Choice C, positioning the client on the left side, is not as urgent as fluid replacement. Choice D, preop teaching for surgery, is not relevant in this post-operative scenario.
A 23-year-old female patient is considering intrauterine device (IUD) contraception. What is the most important information to assess before placement?
- A. Is there any family history of heart disease?
- B. Are you allergic to any metals?
- C. Have you had any previous IUDs inserted?
- D. Do you have a history of hypertension?
Correct Answer: B
Rationale: The correct answer is B: Are you allergic to any metals? This is crucial because some IUDs contain metals like copper, which can trigger allergic reactions in individuals with metal allergies. It is important to assess for metal allergies to prevent potential adverse reactions.
Incorrect Choices:
A: Family history of heart disease is not directly relevant to IUD placement.
C: Previous IUD insertions are important for clinical history but do not impact the initial assessment for a new insertion.
D: History of hypertension is important for overall health assessment but does not directly affect IUD placement.
The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
- A. Blood pressure of 100/60 mmHg.
- B. Fetal heart rate of 90 beats/minute.
- C. Client reports warmth in the lower extremities.
- D. Contractions every 5 minutes.
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.