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A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth(NPO) status and is receiving intravenous(IV) fluid replacement therapy. In planning this client's care, the nurse should collaborate with the health care provider(HCP) to carry out which of the following?
- A. Withhold oral fluids indefinitely until acidosis is corrected.
- B. Give oral fluids in small quantities whenever the client desires.
- C. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
- D. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.
Correct Answer: C
Rationale: Gradual reintroduction of oral fluids is appropriate once vomiting subsides.
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The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
- A. Sitting with back arched.
- B. Lying flat on back.
- C. Side-lying with knees bent.
- D. Prone with head elevated.
Correct Answer: A
Rationale: The sitting position with the back arched (e.g., 'shrimp' position) provides optimal access to the lumbar spine for epidural placement. Other positions do not facilitate needle insertion as effectively.
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should:
- A. Maintain continuous fetal monitoring.
- B. Encourage family members to remain at bedside.
- C. Assess reflexes, clonus, visual disturbances, and headache.
- D. Monitor maternal liver studies every 4 hours.
Correct Answer: C
Rationale: Monitoring signs of CNS irritability such as reflexes, clonus, visual disturbances, and headache helps detect worsening preeclampsia.
A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?
- A. Humidify the air being delivered.
- B. Cover the neonate's scalp with a warm cap.
- C. Record the neonate's temperature every 3 to 4 minutes.
- D. Assess the neonate's blood glucose level.
Correct Answer: A
Rationale: Humidifying the air prevents drying of the mucous membranes and maintains airway moisture, which is critical for preterm neonates.
A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 reflexes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will first include:
- A. Administration of glucocorticoids(Betamethasone).
- B. Vaginal or cesarean delivery of the fetus.
- C. Prevention of seizures with phenytoin (Dilantin).
- D. Reduction of fluid retention with thiazides.
Correct Answer: B
Rationale: Delivery is the definitive treatment for severe preeclampsia.
The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?
- A. Candida albicans infection.
- B. Twin-to-twin transfer.
- C. Polyhydramnios.
- D. Preeclampsia.
Correct Answer: B
Rationale: Twin-to-twin transfer is not a complication of diabetes.