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 Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
You may also like to solve these questions
The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
- A. To decrease the frequency and severity of variable decelerations.
- B. To minimize the possibility of fetal metabolic alkalosis.
- C. To increase the fetal heart rate accelerations during a contraction.
- D. To raise the amniotic fluid index to more than 15 cm.
Correct Answer: A
Rationale: Amnioinfusion replaces amniotic fluid in oligohydramnios, reducing cord compression and the frequency/severity of variable decelerations. It does not affect metabolic alkalosis, heart rate accelerations, or guarantee a specific fluid index.
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?
- A. Bradycardia.
- B. High-pitched cry.
- C. Sluggishness.
- D. Hypocalcemia.
Correct Answer: B
Rationale: A high-pitched cry is a common sign of cocaine withdrawal in neonates, indicating neurological irritability.
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following?
- A. Steps briskly when held upright near a firm, hard surface.
- B. Pulls both arms and does not move the chin beyond the point of the elbows.
- C. Turns head to the left, extends left extremities, and flexes right extremities.
- D. Extends and abducts the arms and legs with the toes fanning open.
Correct Answer: C
Rationale: The tonic neck reflex involves the neonate turning the head to one side, extending the extremities on that side, and flexing the opposite side.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.