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A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
- A. Intensity of pain with contraction.
- B. Fetal heart rate.
- C. Temperature, pulse, and respirations.
- D. Deep tendon reflexes and clonus.
Correct Answer: D
Rationale: Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.
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The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?
- A. Improving kidney function.
- B. Supporting liver health.
- C. Preventing arrhythmias.
- D. Lowering cholesterol levels.
Correct Answer: A
Rationale: Hydralazine's vasodilation lowers blood pressure, improving renal perfusion and kidney function, critical in preeclampsia management.
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Yogurt.
- B. Whole milk.
- C. Collard greens.
- D. Strawberries.
Correct Answer: D
Rationale: Strawberries are a good source of folic acid, suitable for the client's dietary restrictions, unlike yogurt, milk, or collard greens, which either lack folic acid or are disliked.
A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
- A. Color of amniotic fluid.
- B. Maternal temperature.
- C. Deep tendon reflexes.
- D. Maternal blood pressure.
Correct Answer: B
Rationale: Prolonged ROM increases infection risk, necessitating frequent maternal temperature monitoring to detect chorioamnionitis early.
The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
- A. Offer a pacifier dipped in glucose water.
- B. Give a PRN dose of liquid acetaminophen.
- C. Place petrolatum gauze dressings on the site.
- D. Wrap the infant in warm receiving blankets.
Correct Answer: C
Rationale: Petrolatum gauze prevents wound adherence to diapers, reducing irritation and infection risk, prioritizing post-circumcision care.