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A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols
- B. Discontinue the methadone right away
- C. Sign up for group therapy sessions
- D. Start a prenatal care plan as soon as possible
Correct Answer: D
Rationale: Early prenatal care is critical for monitoring maternal and fetal health, managing opioid addiction with methadone under medical supervision, and addressing potential complications.
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The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
- A. Insert a Foley catheter with a urimeter to monitor hourly output
- B. Have calcium gluconate immediately available
- C. Provide a quiet environment with subdued lighting.
- D. Assess deep tendon reflexes (DTRS) every 4 hours.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause neuromuscular blockade, making calcium gluconate, the antidote, critical to have immediately available in case of toxicity signs like loss of deep tendon reflexes.
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Strawberries
- B. Collard greens.
- C. Whole milk
- D. Yogurt
Correct Answer: A
Rationale: Strawberries provide a moderate amount of folic acid and are suitable given the client's dislike for green leafy vegetables and soy allergy.
The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
- A. Calcium.
- B. Iron
- C. Folic acid.
- D. Vitamin D.
Correct Answer: C
Rationale: Folic acid is essential for preventing neural tube defects, including anencephaly, and is recommended for women of childbearing age.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Level of pain sensation.
- B. Variability of fetal heart rate
- C. Maternal blood pressure
- D. Station of presenting part
Correct Answer: C
Rationale: Epidural anesthesia can cause a sudden drop in maternal blood pressure, which may affect placental perfusion, making blood pressure monitoring the priority.
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.