Nokea
A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following?
- A. 1+.
- B. 2+.
- C. 3+.
- D. 4+.
Correct Answer: C
Rationale: Hyperactive reflexes are documented as 3+.
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The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?
- A. "If the fetus is becoming less active than before."
- B. "If it takes longer each day for the fetus to move 10 times."
- C. "If the fetus stops moving for 12 hours."
- D. "If the fetus moves more often than 3 times an hour."
Correct Answer: D
Rationale: Increased fetal movement can be a sign of distress, so the client should be instructed to report any significant changes in movement.
A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do next?
- A. Administer ibuprofen (Motrin).
- B. Reassess in 1 hour.
- C. Catheterize the client.
- D. Administer an I.V. bolus of 500 mL to rehydrate per policy.
Correct Answer: C
Rationale: A deviated fundus and small void suggest bladder distention, requiring catheterization to empty the bladder.
A client is induced with oxytocin (Pitocin). The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
- A. Turn the client to her left side.
- B. Administer oxygen via facemask at 10 to 12 L/minute.
- C. Notify the health care provider of the situation.
- D. Document fetal well-being.
Correct Answer: D
Rationale: Fetal heart rate accelerations with movement indicate fetal well-being, requiring no intervention beyond documentation. Repositioning, oxygen, or notification are unnecessary.
A client asks about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods like condoms.
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
- A. Oval.
- B. Square.
- C. Diamond shaped.
- D. Triangular.
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.