Nokea
A nurse suspects that a pregnant client may be experiencing placenta abruption based on which finding? Select all that apply.
- A. Absence of pain
- B. Insidious onset
- C. Dark red vaginal bleeding
- D. Rigid uterus
- E. Absent fetal heart tones
Correct Answer: C,D,E
Rationale: Placental abruption involves sudden separation of the placenta, causing severe pain, a rigid uterus from bleeding, dark red vaginal bleeding due to clotted blood, and absent fetal heart tones if the fetus is compromised. Absence of pain and insidious onset are not typical, as abruption is acute and painful.
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A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
- A. Difficulty in arousing
- B. Deep tendon reflexes 2+
- C. Urinary output of 30 mL per hour
- D. Respiratory rate of 10 breaths/minute
Correct Answer: B
Rationale: Deep tendon reflexes at 2+ indicate a therapeutic magnesium level, preventing seizures without toxicity. Difficulty arousing, low urinary output (below 40 mL/hr), or respiratory rate of 10 suggest toxicity, requiring intervention.
Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
- A. Recurrent pelvic infections
- B. Ovarian cyst 2 years ago
- C. Use of oral contraceptives for 8 years
- D. Heavy, irregular periods
Correct Answer: A
Rationale: Recurrent pelvic infections (e.g., PID) scar fallopian tubes, increasing ectopic pregnancy risk by hindering egg transport. Ovarian cysts, oral contraceptives (which reduce risk), and irregular periods don't directly contribute.
A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make?
- A. Be sure that your lupus is stable or in remission for 6 months before getting pregnant.
- B. It's probably not a good idea for you to get pregnant since you have lupus.
- C. Your lupus will not have any effect on your pregnancy whatsoever.
- D. When you get pregnant we'll have to add quite a few medications to your normal treatment plan.
Correct Answer: A
Rationale: Stable lupus for 6 months before pregnancy reduces risks like flares or miscarriage. Discouraging pregnancy is insensitive, claiming no effect is false, and adding many medications is inaccurate without specifics.
Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
- A. Ferrous sulfate
- B. Potassium chloride
- C. Calcium carbonate
- D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate reverses magnesium toxicity (e.g., respiratory depression), a risk with magnesium sulfate used for preeclampsia. Ferrous sulfate treats anemia, potassium chloride corrects hypokalemia, and calcium carbonate is an antacid, none addressing toxicity.
A provider prescribes quetiapine 50 mg PO divided equally every 12 hours for 3 days. Available is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on day 3?
- A. 2 tablets
- B. 1 tablet
- C. 3 tablets
- D. 4 tablets
Correct Answer: B
Rationale: Daily dose (50 mg) ÷ 2 (every 12 hours) = 25 mg per dose. At 25 mg/tablet, 25 mg ÷ 25 mg = 1 tablet per dose, consistent on day 3 as dosing doesn't change.