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 who gave birth 1 week ago. The client states, "I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason." The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression
- B. Taking-in phase
- C. Postpartum blues
- D. Taking-hold phase
Correct Answer: C
Rationale: The client is likely experiencing postpartum blues, which is common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
- B. A client who gave birth 3 days ago and reports breast fullness
- C. A client who gave birth 12 hr ago and reports an increase in urinary output
- D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour
Correct Answer: D
Rationale: The client saturating a perineal pad every hour may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus Ÿ-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin
- B. Azithromycin
- C. Ceftriaxone
- D. Acyclovir
Correct Answer: A
Rationale: Ampicillin is the recommended antibiotic for treating group B streptococcus infections in pregnant women during labor to prevent neonatal infection.
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications.
A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.