Nokea
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.
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A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct Answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void, which will allow the uterus to return to midline and become firm.
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct Answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia
- B. Cord compression
- C. Uteroplacental insufficiency
- D. Head compression
Correct Answer: D
Rationale: Early decelerations are typically caused by head compression during contractions, which is a normal response and often indicates that the fetus is descending into the birth canal.
A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will leave the diaphragm in place for 4 hours following intercourse.
- B. I will remove the diaphragm by catching the rim below the dome with my finger.
- C. I will place a thin layer of mineral oil on the diaphragm once per week.
- D. I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.
Correct Answer: D
Rationale: The client should place spermicide in the diaphragm before insertion to enhance contraceptive effectiveness. The diaphragm should also be left in place for at least 6 hours after intercourse, but not more than 24 hours.