Nokea
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
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A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
- A. Fat.
- B. Iron.
- C. Sodium.
- D. Calcium.
Correct Answer: A
Rationale: Breast milk has higher fat content, which is essential for neonatal growth and brain development.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
- A. The molding was caused by an overlapping of the baby's cranial bones during my labor.'
- B. The amount of molding is related to the amount and length of pressure on the head.'
- C. The molding will usually disappear in a couple of days.'
- D. Brain damage may occur if the molding doesn't resolve quickly.'
Correct Answer: D
Rationale: Cranial molding is a normal process that resolves within days and does not cause brain damage, indicating the mother needs further instruction.
A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 6 hours before intercourse.
- B. Remove the diaphragm immediately after intercourse.
- C. Use a spermicide with the diaphragm for each act of intercourse.
- D. Store the diaphragm in a dry, airtight container.
Correct Answer: C
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. The diaphragm can be inserted up to 6 hours before and left in place for at least 6 hours after intercourse but not more than 24 hours. It should be stored in a clean, dry container, not necessarily airtight.
After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?
- A. As my child grows, she may have increased fatigue and difficulty breathing.'
- B. My child may need to have antibiotics if she develops an infection.'
- C. This condition occurs more commonly in females than in males.'
- D. About half of the children born with this defect heal spontaneously.'
Correct Answer: C
Rationale: Atrial septal defects are not significantly more common in females, indicating a need for further instruction.