Nokea
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
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During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. The neonate is diagnosed with patent ductus arteriosus, for which the neonate received indomethacin. An expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosus is:
- A. Closure of a patent ductus arteriosus.
- B. Decreased bleeding time.
- C. Increased gastrointestinal function.
- D. Increased renal output.
Correct Answer: A
Rationale: Indomethacin promotes closure of the patent ductus arteriosus by inhibiting prostaglandin synthesis.
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.
The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
- A. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
- B. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
- C. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
- D. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.
Correct Answer: C
Rationale: Severe preeclampsia requires immediate attention.
The nurse is administering intravenous magnesium sulfate as ordered for a client at 34 weeks' gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? Select all that apply.
- A. T 98, P 72, R 14.
- B. Urinary output<30 mL/hr.
- C. HR 120 BPM.
- D. Fetal heart rate with late decelerations.
- E. BP of <140/90.
- F. DTR's 2+.
- G. Magnesium level= 5.6 mg/dL.
Correct Answer: A,E,F,G
Rationale: Desired outcomes include stable vital signs, absence of late decelerations, and controlled deep tendon reflexes.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.